Issues in Bioethics: A Brief History and Overview

Issues in Bioethics:
A Brief History and Overview
by
Gabriel Tordjman
FOR ISSUES IN BIOETHICS
HUMANITIES 345-BXH-DW
DAWSON COLLEGE,
WESTMOUNT, QC
WINTER 2015
Contents
PART I: INTRODUCTION ................................................................................................... 1
A. What is Ethics? .............................................................................................................. 1
B. Subjectivism and Ethical Relativism ............................................................................. 2
PART II: ETHICAL PRINCIPLES & THEORIES ............................................................... 5
A. Religious and Philosophical Ethics ............................................................................... 5
B. Descriptive and Normative Philosophical Ethics........................................................... 5
C. Ethical Principles, Legal Principles and Codes of Ethics .............................................. 7
D. Ethical Theories ........................................................................................................... 10
2. Utilitarianism ............................................................................................................ 11
3. Deontology or Kantian theory .................................................................................. 12
4. Natural Law Theory.................................................................................................. 14
5. Contractarianism (Social Contract Theory) and Natural Rights............................... 14
6. The ethic of care ....................................................................................................... 16
PART III: THE GROWTH OF MEDICINE & THE BIRTH OF BIOETHICS .................. 17
A. Beginnings ................................................................................................................... 17
B. The Increasing Impact and Power of Medicine & the Life Sciences ........................... 18
C. The Biological Revolution ........................................................................................... 19
D. Human Experimentation, Nuremberg Code & Foundation of Bioethics ..................... 21
PART IV: BIOETHICS: DEFINITION & KEY ETHICAL PRINCIPLES ........................ 24
A. Definition of Bioethics ................................................................................................ 24
B. Key Ethical Principles in Bioethics ............................................................................. 26
PART V: BIOETHICAL ISSUES ........................................................................................ 27
A. Issues #1 & 2: Human Experimentation & Torture ..................................................... 27
1. Cold War Background: A Canadian Cold War Connection ..................................... 27
2. Dr. Ewan Cameron’s Experiments at the Allan Memorial in Montreal ................... 27
3. Dr. D.O. Hebb’s Sensory Deprivation Experiments at McGill University............... 28
4. From Defensive Theory to Offensive Practice ......................................................... 29
5. 9/11 and Beyond ....................................................................................................... 29
6. 9/11 and Beyond: Canadian Involvement ................................................................. 30
B. Issue #3: Euthanasia ..................................................................................................... 31
1. Nazi Germany and the “Action T4 Program” ........................................................... 31
2. What is Euthanasia? .................................................................................................. 32
3. Euthanasia in the Netherlands................................................................................... 34
4. Euthanasia in Canada ................................................................................................ 34
5. The Current Euthanasia Debate in Quebec ............................................................... 36
C. Issue #4: The Health Care Debate................................................................................ 38
1. Introduction............................................................................................................... 38
2. The Health Care Debate in Canada: A Brief Summary ............................................ 39
3. Health Coverage and Access in the USA ................................................................. 45
4. Conclusion and Ethical Reflection ........................................................................... 47
D. Issue #5: Genetic Technology...................................................................................... 48
1. Background: Discovering the Structure and Function of DNA (1940-53) ............... 48
2. Gene Mapping and Sequencing (1976-1999) ........................................................... 51
3. Bacteria and Viruses as Genetic Engineering Tools ................................................. 52
4. Some Current Applications of Recombinant DNA Science and Technology .......... 53
CONCLUSION ................................................................................................................ 58
Bibliography ......................................................................................................................... 60
Gabriel Tordjman
Issues in Bioethics
Winter, 2015
Gabriel Tordjman
Issues in Bioethics
Winter, 2015
PART I: INTRODUCTION
A. What is Ethics?
Before explaining what bioethics is, let’s first look at the term ethics. Ethics deals
with questions of right and wrong, good or bad and our moral obligations to others as
well as ourselves. Sometimes words, like morality, morals, values and others have been
used as synonyms for ethics. Writers specializing in these matters make distinctions
between these words but we will deal with these later.
The importance of ethics should be clear since we make ethical judgments and
decisions every day. Indeed, the ability to make ethical decisions has often been considered
a key difference between humans and other animals. These decisions affect the people and
the world around us, though it may be all too easy to ignore this at times. That is one reason
it is important to examine ethics, including our own ethics. Since our ethical choices affect
others this also tells us that ethics is largely a social matter, dealing with how we get along
with others. But besides the impact our ethics has on others, ethics is important also because
it is something that is key in defining who we are as
individuals. As Daniel Maguire says
Moral values are more basic than all other values, because moral values touch, not
just on what we do or experience or have, but on what we “are.” It is admittedly
unfortunate if a person is not gifted with the values of wealth, gracefulness,
beauty, education, and aesthetic sophistication. But it is a qualitative leap beyond
the merely unfortunate if a person is a murderer, a liar, or a thief. Here the failure
is at the level of what a person is and has to be as a person. (Quoted in Kammer,
8).
In short, our ethics tells us what kind of person we are. An ethics course is thus not just
about learning what others have said or written but it is about learning about our own
ethics and becoming conscious about the decisions we make and this is what makes up a
big part of the kind of person we are or want to be. But this is not a course that tells you
what to think or what is right and wrong. Instead, it tries to help you find out about how
to think about matters of right and wrong. What is right and wrong is up to you to decide.
The course only demands that you provide good reasons for your ethics and for the
values you have and that you are willing to question your beliefs, a key requirement of
the philosophical approach to ethics. This is how we become more aware of and shape
who we are.
An easy way to understand the importance of ethics and how it defines a person is to
recall how we feel about the villains we encounter, either in real life or fiction. Psychologist
Philip Zimbardo has looked into real life examples of evil but his concern is not so much
with evil doers but with most of us, who, he claims, are all too vulnerable to accepting evil
and injustice. On the flip side, he also examines what makes people able to stand up to evil
or become “heroes” and his insights provide us with a valuable lesson on
the importance of ethics and ethical principles. We examine some of his findings in the
beginning of the course.
We look briefly, as well, at what some of the great philosophers of the past have
taught us on this issue. In many cases they provide useful intellectual tools for examining
our ethics. Though they often disagree on moral questions, they can still provide us with
a way of questioning, clarifying and making more consistent our own ethical philosophy. In
this way they can contribute to our growth as human beings.
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Later in the course we look at important bioethical issues using some of the ethical
principles and theories examined below. Some of these issues include controversial human
experimentation conducted in Montreal, torture and “extraordinary rendition”, the current
debate about euthanasia in Canada and Quebec, genetic engineering and technology and,
finally, an examination of the environmental and ethical impact of the Alberta Tar Sands
project.
B. Subjectivism and Ethical Relativism
Many people have noted how there is wide disagreement even among experts and
philosophers on what is right on wrong on almost every important issue. They note how
there are a multitude of theories and principles that often give entirely different answers to a
moral problem. This is in especially sharp contrast to what we learn in science classes.
After all there is no rival theory to the theory of gravity! Some are frustrated at this and
conclude that there is no right and wrong in ethics. Many people believe that ethical or
moral viewpoints are an entirely private or even largely subjective affair. Subjective, here,
means true from the point of view of one person (the subject) rather than objective (valid
independently of the viewpoint of one, many or even most persons). The assumption made
here is that unlike, for example, physics or mathematics, there is “no right answer” thus
there is no real possibility of arriving at objective ethical judgments. In this field ethics is
really “all relative to the individual”. Those who hold this view seem to think that ethics is
about how you feel about something or how you perceive something. If you think killing is
wrong, this is simply like saying that you don’t like killing but it doesn’t mean killing is
“really” or “objectively” wrong. For subjectivists there is no way to establish that anything is
“objectively” wrong, it’s just about how the individual feels or sees things. Subjectivism is
sometimes called individualistic “ethical relativism”.
Cultural relativism is one form of ethical relativism but claims that right or wrong
depends not on the individual’s views but entirely on the culture the individual is raised in.
Thus it may be “wrong” for one person to kill another innocent person in our culture. But if
another culture says it’s alright to kill another innocent person, then it is ethical to kill
others in that culture. If we asked a cultural relativist which culture is right he or she would
answer that there is no way to establish which culture is “really” or “objectively” right or
wrong. Each culture’s values cannot be judged by the values of any other culture or any
outside yardstick.
The relativist and subjectivist viewpoints may contain some truth in that ethical
viewpoints do contain a larger element of “subjectivity” than the natural sciences. It is also
undeniably true that value systems change from one time period to another, from one
culture to another and even from individual to individual within a given culture. So how can
we justifiably claim that a particular ethical view is ever universally valid? In addition, we
know how people often behave when they are convinced that their moral perspective is the
only valid, objective one: they try to impose their views on others or even worse. Believing
there is an objective truth in ethics thus seems intolerant to many people and that is why
they often favour relativism.
We can respond to this in a number of ways. Firstly, the fact that moral judgments
are often subjective to various degrees doesn’t mean they are completely and necessarily
always subjective. Some degree of objectivity is often possible and this can be evaluated by
the factual support and logical consistency one provides for their moral judgments. In this
way, moral judgments are like any good theory – the more facts and logic to support it, the
better the theory or moral judgment. However, one needs to remember that there will often
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be a degree of uncertainty and possible bias that may make some moral judgments more
probabilistic than absolute. We need always to maintain an open mind and be willing to
change our conclusions – something that sounds a lot easier than it really is!
Secondly, the fact that value systems change from place to place, time to time and
person to person proves just that: people’s views do in fact differ. It doesn’t prove that all of
these viewpoints are equally valid (or equally invalid) and leaves untouched the possibility
that there may be one or a few that are closer to the “objective truth” than others. The fact
that some societies practiced or still practice slavery, for example,
doesn’t make that practice right or doesn’t mean that we cannot judge it to be wrong. The
mistake here is in not distinguishing between what people actually or factually think and do
– a question of descriptive ethics – and what they should think and do – a question of
normative ethics. From the viewpoint of normative ethics, just because people have
differing moral values doesn’t mean all these moral values are correct. And just because
“everyone” believes something to be true, doesn’t make it true. Again, to judge which, if
any moral viewpoint is correct, we need to examine the reasons (facts and logic) behind it.
Thirdly, when we actually try to argue for ethical relativism, we are in fact claiming
that it is the “best” or the most “truthful” viewpoint and this immediately involves us in a
logical contradiction. We find ourselves arguing that the best viewpoint is one that claims
that there are no best viewpoints. In this case it would be logically impossible to even argue
for ethical relativism. A really committed ethical relativist
might then maintain that logical consistency is itself not applicable to ethics because ethics
are a matter of taste, like the fact that I like coffee in the morning while you prefer tea. On
such matters, there is no debating of right and wrong, these are just personal preferences.
That would mean, however, that we could not judge as wrong even things we “know” are
wrong, like the killing of babies or other forms of murder. Clearly, there is something
wrong with saying that murder is just someone’s preference, like whether
she likes coffee or tea.
This leads us to a final point: relativists tend to exaggerate differences and
underplay similarities in our moral values that would strengthen the case for objectivity in
ethics. The source of this objectivity comes from the fact that, as human beings, we have
certain common characteristics, including similar bodies, a rational mind, feelings,
language, social life, and a certain amount of empathy for our fellow human beings and
other living creatures. These basic characteristics are common to most adult individuals in
all societies in the world and are part of our human nature or human condition. The moral
part of this common human nature may be called our moral intuitions, a kind of “moral
common sense”1 that we recognize immediately as a twinge of conscience whenever we
know we have done something wrong. It is what makes us say that murder or killing of
innocent life is wrong, despite the arguments of ethical relativism or subjectivism.
Moral intuitions may be a product of social and parental teaching or might even be
built into us biologically, as some have claimed. Whatever their origins, they provide one
source of moral guidance, though perhaps not always a clear, justifiable or reliable one.
Some ethical theorists view our moral intuitions as one source (not the only source) for
particular moral traditions, for example, Christianity, or Islam or Hinduism, etc. Moral
intuitions may also be at the basis of secular (non-religious) or philosophical ethics as
well, such as Kantian ethics and utilitarianism. In this sense, all religious and philosophical
moral traditions are simply different ways different cultures have had of formulating,
developing and expressing a common moral nature or our basic moral intuitions. In fact, as
the German philosopher Immanuel Kant showed, no society exists, or can exist, where
killing, lying or stealing is accepted as the norm. The existence of moral intuitions and the
1
Examples of moral intuitions may include the rules that we should not kill, steal or tell lies.
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fact that no society exists without moral systems based partly on them suggests that ethics
are or can be objective, at least in some measure.
As such, we can argue, convince, defend and rationally discuss the merits of our
ethical viewpoints and judgments, something we could not do if these were merely a matter
of taste. But within this common basis for moral guidance, we recognize, of course,
substantial differences between cultures and religions throughout the world and even some
variations between individuals belonging to the same culture and religion. Because all
moral systems in the world may be based, in part, on moral intuitions does not mean that all
moral systems will be identical. It does mean, however, that there is a possibility of
reaching at least partial agreement and objective understanding on what constitutes right
and wrong action. Ethical relativism is thus wrong in denying that there is a common,
objective basis to morality and claiming that morality is just a matter of individual taste.
Ethical relativism is thus an untenable and inadequate theory of ethics.
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PART II: ETHICAL PRINCIPLES & THEORIES
A. Religious and Philosophical Ethics
In the past and still today, much of our ethics was shaped by custom, tradition and
religion. This is what we can call religious ethics. Religious ethics is based on the idea of
obedience to divine commands and the divine will. In religions like Judaism, Christianity
and Islam this divine will is believed to have been revealed in sacred books like the Bible or
the Koran. Of course, there are differing interpretations of exactly what the divine will
(God’s will) is and we find that people even from the very same religious traditions differ
considerably in their ethical conclusions on key topics like abortion, euthanasia and capital
punishment.
Religious Ethics is still influential in our society but differs in key respects from
philosophical ethics. Philosophical ethics is a field of study which seeks to apply reason
and fact to clarify ethical questions and to contribute to making better and wiser decisions.
A big difference between religious and philosophical ethics centers around the role of
reason. In religious ethics the first priority is obedience to the divine will while in
philosophical ethics the first priority is to submit everything to rational and logical
questioning.
Because it stresses reason and fact, philosophical ethics can provide a common
denominator wherein all of us, regardless of our religious or cultural backgrounds, can
discuss ethical issues or issues of right and wrong. This is a big advantage in a multicultural
society like Canada where there are so many differing traditions, religions and viewpoints.
The key requirement for philosophical ethics is that one is willing to question his or her
own beliefs and support them by appeal to facts and reason. This sounds easier than it is
since ethical and moral issues, can be quite personal, controversial and emotional. In this
course, we try to use the approach of philosophical ethics without ignoring the other
important traditional and religious sources of ethics.
B. Descriptive and Normative Philosophical Ethics
Philosophical ethics can be divided into two main groups: descriptive ethics, which
explains or describes the moral viewpoints people actually have (“what is”), and normative
ethics, which prescribes the moral viewpoints people should have and the actions people
should undertake (“what ought to be”). Descriptive ethics is supposed to provide an
accurate description of what people’s ethics are. These can sometimes be learned from
opinion polls or other such studies. But of course, the ethics or values people actually have
may or may not be right or good when judged by the light of fact and reason. Normative
ethics questions what people’s ethics are and shows their failings and inconsistencies while
(hopefully) providing us with some amount of guidance in difficult moral situations about
what they should be. The difference is one between description versus prescription or
between “what is” and “what should be”. However, there are a number of rival ethical
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theories that often seem to provide opposing views of “what should be” in any given case,
as we shall see.
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C. Ethical Principles, Legal Principles and Codes of Ethics
Should one always tell the truth to a friend even though this might hurt our friend’s
feelings? Should loyalty or sympathy to a friend come before honesty? Here loyalty and
honesty are examples of ethical principles (like ethical rules) many of us follow. These
principles can be like guides to doing the right thing and most of the time they probably
work well. Just working out and writing down one’s own ethical principles is an interesting
and valuable exercise in philosophical ethics. Here are some well known ethical principles:
Sanctity of human life (a religious ethical principle)
Thou shalt not kill (a religious ethical principle)
respect for life
confidentiality or privacy (e.g., of patients’ medical information)
autonomy (the freedom to act according to one’s own wishes)
beneficence (doing good)
nonmaleficence (not doing harm)
justice
equality
But sometimes these principles can be in conflict, as in the example above. Philosophical
ethics can help in resolving or at least clarifying such difficult ethical dilemmas. Reasoning
things out with the help of philosophical ethics can help find a better solution to ethical
dilemmas than just acting from emotion or without thought. In particular, ethical theories
(mentioned later) are key parts of philosophical ethics that may help resolve clashes
between ethical principles.
Codes of Ethics
Besides one’s own personal ethical principles, more examples of ethical
principles can be found listed in codes of ethics produced by doctors, nurses and many
other professional associations. Ethical principles are often no more than a list of rules
allowing, commanding or prohibiting certain acts. One famous example in religious
ethics are the Bible’s Ten Commandments’ “thou shalts” and thou shalt nots”. The Ten
Commandments are a type of code of ethics intended for an entire community. But codes
of ethics are rules more often written up and intended for the practitioners of specific
occupations, like doctors, nurses, teachers, policemen, engineers, etc…Thus the famous
Hippocratic Oath, after invoking Apollo and other deities as witnesses and establishing
the duties and obligations physicians have towards each other and their patients, includes
statements such as:
“I will apply dietetic measures for the benefit of the sick according to my ability and
judgment; I will keep them from harm and injustice.”
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“I will neither give a deadly drug to anybody if asked for it, nor will I make a
suggestion to this effect. Similarly I will not give to a woman an abortive remedy…” (“The
Hippocratic Oath” in Edelstein, 43)
Similarly, the Canadian Medical Association Code of Ethics includes in its first section,
seven different statements of principle outlining the behaviour expected of the ethical
physician:
I. Consider first the well-being of the
patient. II. Honour your profession and
its traditions.
III. Recognize your limitations and the special skills of others in the
prevention and treatment of disease.
IV. Protect the patient’s secrets.
V. Teach and be taught.
VI. Remember that integrity and professional ability should be your best
advertisement. VII. Be responsible in setting a value on your services. (“The
Canadian Medical Association Code of Ethics,” in Kluge (ed.), pp.536-540)
Codes of ethics like the ones mentioned above are simply lists of ethical principles. But
again, sometimes different principles can conflict. A doctor, for example, may have sworn
an oath to do whatever she can to preserve the life of a patient. But what if that patient is
suffering from a painful and incurable disease and requests the termination of lifesustaining treatments? Should the doctor follow the principle of preserving life or respect
the wishes of the patient (autonomy)? Also, what exactly does “the well-being of a patient”
mean? Does it mean preserving the life of the patient regardless of the pain a patient might
be facing or regardless of the wishes of the patient? Here a definition and interpretation of
“well-being” is needed and so is a way to resolve a possible clash between the principles of
respect for human life with other principles. Because they are just lists of principles, codes
of ethics don’t provide this. What is needed is philosophical reasoning and ethical theory.
Legal Principles
Ethical principles are also found in another set of rules and that is the law. Like codes of
ethics, the law is enshrined in legal codes that contain legal principles that we are bound to
follow or face jail, fines or other consequences. These legal principles reflect to some
extent (but not always) ethical principles that are widespread in society. However, like all
lists of principles, they cannot provide a complete guide to all situations and require
interpretation, definition and argument and reasoning. Otherwise, we wouldn’t need judges,
lawyers and courts! As with codes of ethics, legal principles can often clash and a way to
resolve dilemmas between legal principles is needed. Clashes can occur because one
principle or section of the same legal code may apparently contradict another, or, because,
as in Canada, there are different legal codes, such as municipal bylaws, provincial laws and
federal laws. One partial solution to this is to establish one set of laws as the “highest” and
most important in the land. In the United States, this is called the Constitution and it
contains key principles which all other laws must not contradict or violate.
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The Canadian Charter of Rights and Freedoms, passed in 1982, is the highest
law in Canada. Section 7 of the Charter states “Everyone has the right to life, liberty and
security…” but does “liberty” here mean that a patient has the right to end life-sustaining
treatments? Does “the right to life” here mean that women do not have the right to have
abortions? Even having a “highest law” doesn’t remove all questions. Again, just as we saw
with other lists of principles, legal principles need to be defined, interpreted, and argued so
that clashes between principles can be clarified and resolved.
Even if the law is clear, which is not always the case, is what it dictates always the
right thing to do? Many people disagree with current laws dealing with abortion,
euthanasia, capital punishment, drug enforcement and much more. Though as citizens we
are bound to follow the law or suffer the consequences, that doesn’t mean the law is always
ethically right. Not so long ago, the law protected slavery and did not allow women the
vote. Today we would see this as wrong. The ethics of our society have changed since then
and the laws have changed accordingly.
In some ways the law is a reflection of a consensus, agreement and compromise
about what a large segment of society believes at any given time. Critics, however, maintain
the law is often written by the powerful minority to serve mainly their interests. But even if
a majority of people believe in something, does that make it right? All of the above shows
that just because we have rules or principles to follow, that doesn’t mean they provide an
answer to every possible situation or that even when they do, the rules are not always right
or ethical. There may sometimes be a big difference between what is legal and what is
ethically right. We need to be able to interpret these rules or principles and also to question
them by asking what factual or logical support they have. Sometimes, when principles
conflict we will need to set priorities but even that requires reasoned justification. Just like
in assessing our own personal ethics, we need to use the reasoned approach of philosophical
ethics to see if the ethics of our society, enshrined partly in the law, are well supported.
Philosophical ethics provides ethical theories that can help in this task but, as we will see,
they don’t provide a perfect answer either!
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D. Ethical Theories
Ethical principles may play an important role in establishing the ethical standards of
a profession or an institution but they are not ethical theories. Ethical principles present no
argument as to why an ethical principle exists or is valid, and often cannot adequately deal
with situations in which ethical principles clash. The Hippocratic injunction to do no harm,
for example, may conflict with other principles, such as the relief from pain. In addition,
ethical principles often leave unsettled key definitions of basic concepts such as “health”,
“well-being” or even the meaning of “good” or “harm” and other terms. Presenting a
reasoned argument, definitions, and interpretations that provides a more complete,
consistent and connected ethical viewpoint is the job of an ethical theory. Like science,
philosophical ethics tries to develop theories that can be used both to explain and support
ethical viewpoints as well as to provide guides to decision-making action. Such ethical
theories also are intended to help resolve the problem of conflicting principles mentioned
above and thus arrive at satisfactory ethical decisions. The questioning and clarification of
what these principles are and what good or bad or evil is, are what ethical theories are
supposed to do. Furthermore, ethical theories try to establish worked out systems of ethical
principles or rules that fit together logically without contradicting themselves and not just
disconnected lists of principles.
The word “theory” here does not mean something unsure but, as in science, a fairly widely
accepted explanation, as in the “theory” of gravity. As mentioned above, a key assumption
of most philosophical ethics is that it is possible to reach a certain amount of “objective
truth” about issues of right and wrong. By “objective truth” is meant a viewpoint that is not
just true for me or for a particular culture or time but true for everyone even if it is not
accepted by some. Again this is much like what science claims for its laws and theories.
Gravity, for example is not just true for me but is true for all times and places – it is an
“objective” not just a “subjective” (personal) truth. In science, theories like gravity can also
be used to explain many things, like why objects fall to the ground. At the same time, facts
can be used to support the correctness of a theory. Thus, the fact that all objects fall to the
ground when released from a certain height supports the theory of gravity. Of course, any
fact that contradicts the theory would show that the theory is untrue. If I let go of a pencil
and it did not fall to the ground but stayed floating in the air or flew up instead, this would
contradict the theory of gravity.
Unfortunately, unlike in science, there is no single, universally accepted theory of
ethics. There is nothing like a single “theory of gravity” in philosophical ethics that is
accepted by everyone. Instead there are a number of key competing theories we will need to
look at. Though some have claimed that their ethical theory covers all situations, just like
the theory of gravity covers all situations, the fact is that each one has serious weaknesses
and imperfections. Though philosophical ethics, like science, uses facts and reason, it is not
as accurate or objective or reliable as science. But, by using various theories and approaches
and maintaining our commitment to fact and reason, we can still make substantial progress
in coming closer to the truth even if we can’t come to an absolute certainty. This
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“fuzziness” (as compared to science) is typical of all studies that involve examining human
beings and human behavior2.
Many ethical theories are based on a general view of human nature then try to
deduce moral principles like justice and human rights from this general theory. Many
assume a model of society in which individuals compete and conflict in asserting their
individual rights and interests. But all theories, (except for one) accept that there are moral
rules that go beyond mere self-interest. In other words, almost all ethical theories assume
that we have ethical obligations to ourselves and others. Following the Royal Commission
on the New Reproductive Technology, we will examine 6 different ethical theories:
1.
2.
3.
4.
5.
6.
Ethical Egoism
Utilitarianism (or Consequentialism)
Deontology (Kantian ethics)
Natural Law
Social Contract Theory
Ethic of Care (Feminist ethics)
1. Ethical Egoism
This theory asserts that what is moral is simply what fulfills our self-interest. In other
words, it is what many people might term a theory of “selfishness” or simply “egoism”.
Ethical Egoism criticizes and rejects view that there are moral reasons that can restrain or
impede personal self-interest. Action is based on personal desire and self-interest and if
an action does not satisfy these criteria there is no reason to do it. On the other hand, some
ethical egoists advance the view that helping others may be in your own self- interest.
Ethical egoism accepts that it may be in a person’s interest to obey certain rules (e.g. , vs.
theft, injury) as long as everybody else obeys them. Though short-term sacrifice to selfinterest is entailed in obeying these rules, long term interests are protected (for example, the
protection from injury and benefits of co-operation). However, we know
this is not always the case and sometimes helping yourself will harm others and vice versa.
The ethical egoist would say when this happens you should simply help yourself and do
what is in your own interest.
In many ways, this is really not a theory of morality at all, since “moral” by
definition, means some degree of concern for others. Ethical egoism might agree that it is in
my self-interest to obey certain rules but nothing prevents the strong or powerful from
dominating the weak, if this is advantageous to the former. Thus ethical egoism may justify,
in some contexts, the enslavement and oppression of the weak by the strong – hardly a
credible moral normative theory (i.e., a theory about how we should act)!
2. Utilitarianism
Utilitarianism is an ethical theory developed by the British philosopher Jeremy
Bentham (1748-1832) and later refined by John Stuart Mill (1806-1872). According to
this theory, the morally right action is one that creates “the greatest happiness (or
2
This fact, often lamented by students and others and even offered as proof of the irrelevance of normative
ethical theory, should not necessarily be viewed with consternation. It is simply a reflection of an important
lesson in education in the Humanities: there may not be a single, true, key “theory of everything” that will tells
us what to think and do. The real secret is in the continuous search and fair appraisal of rival viewpoints in the
formation of one’s own understanding of life.
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greatest good) for the greatest number”. It is a theory that looks at the maximization of
“well-being” or “happiness” as the main rule deciding ethical action. In other words, to
decide what is good, one has to calculate whether one course of action will result in more
“happiness” or “good” than another course. The right action would then be to choose the
action that follows the greatest happiness or greatest good.
Over many years, utilitarian philosophers have tried to work out the definition of
“happiness,” or “well-being” as well as who should be counted as part of the greater
number. Is “happiness” the same as “pleasure” or is it “something higher”, like “the
good”? “What is the “good”? Does the “greatest good” mean the “greatest good” for the
individual, or for a single society? The whole human race? Or do we include non-human
animals too? The issue of who it is that does the maximizing of happiness (individual,
group, or society) is also debated.
Originally “happiness” was interpreted as “pleasure” and utilitarianism is often
described as a way to calculate how to achieve the most pleasure and the least pain. Later,
under pressure of criticism, other philosophers redefined “pleasure” to mean “happiness”
or “goodness” or “well-being”. Many utilitarian philosopher have also more recently
insisted that the “greatest good” should refer not just to the good of the individual or to
that of a single society but to that of the human race as a whole and even to include many
non-human animals, too. However, there is still disagreement about these matters.
Despite this, most people can easily see that there is at least some validity in a theory that
promotes the greatest good for the greatest number, however we define the various
debatable terms.
Utilitarianism is part of a consequentialist group of theories, in that “happiness”
or “good” is judged by the actual or potential consequences an action has or may have on
everyone, rather than the motives or intentions of the action itself. For consequentialist
theories, no actions or desires are intrinsically good or bad in themselves but good or bad
is judged by consequences. For example, killing someone would normally be considered
bad. But if by killing that someone you could save hundreds of others, then the action
would be good, according to utilitarianism, since you’ve accomplished a greater amount
of happiness or good than of unhappiness or bad. Even if the killing was accidental or
unintended, utilitarians would still consider it a good action because it is results,
outcomes or consequences that matter, not intentions.
As sensible as this sounds, consequentialist theories like utilitarianism do not
always accord with our everyday moral sense, or what some call, our moral intuitions.
Imagine, for example, a physician who wanted to test a potentially dangerous drug on
other human beings. Since a risk of death is involved, he decides to hide this fact from his
subjects and injects them with the substance. He justifies this action by arguing that the
drug could save hundreds of lives at the cost of the lives of only a few experimental
subjects. It thus fits the utilitarian rule of “greatest good for the greatest number,” and
from the utilitarian viewpoint is therefore ethical. This, however, would violate our moral
intuitions and many cherished principles such as the respect for human life, personal
autonomy, informed consent and so forth (see below). In addition, since you are looking
at the possible future consequences, there is no guarantee that the sacrifice of your
subjects will bring any benefit at all. Though utilitarian calculations may sometimes be
very useful, it is clearly not adequate for every possible case.
3. Deontology or Kantian theory
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Deontology is influenced by the German philosopher Immanuel Kant (17241804), who conceived of morality as flowing from an inner sense of duty rather than from
a calculation of external consequences. This sense of duty established what he termed the
categorical imperative. Any act that follows the dictates of the categorical imperative is
moral for Kant and any act that violates it is immoral. However, there are three
formulations of this categorical imperative:
(i) The universalizing maxim. Act as if your will were also a universal law.
(ii) Respect for rational agents. Always respect people as rational agents.
(iii) The formula of ends. Treat rational agents always as ends in themselves, never merely
as a means to an end.
The connection between these three formulations of the categorical imperative is unclear,
though they all seem connected to our uniquely human rational abilities for Kant. But we
can still explain the key ideas behind each. The universalizing maxim provides criteria for
deciding whether the “will” or intention behind an action, is ethical or not. It asks us to
imagine whether an action we are contemplating would remain valid (logically consistent,
tenable) if everyone acted according to that principle (i.e., if it were a “universal law”). For
example, if I decided to take a loan I know I couldn’t pay back, the principle under which I
acted could be summarized as “Whenever I’m short of money, I will borrow money and
promise to pay it back, though I know I won’t”. To determine whether this is ethical, says
Kant, we should imagine this as a “universal law”, meaning let’s imagine everyone did it
and thought it was acceptable. What would happen if everyone acted according to this
principle? Knowing that people really did not intend to pay back, banks would
obviously stop providing loans. But not only would bank loans become an impossibility,
even promising itself would become an impossibility, because, as Kant states, “…it would
make promising, and the very purpose of promising, itself impossible, since no one would
believe he was being promised anything, but would laugh at utterances of this kind as
empty shams” (Kant 90). In other words no promises would ever be taken seriously and
they would soon cease to exist. Bank loans or other such practices would never even exist
in a world like this because they are based on the assumption that, overall, promises are
intended to be kept. In a world like this, we wouldn’t even be able to ask for loans because
the principle upon which they are founded would not exist or even be possible. For Kant
any principle that “contradicts” or destroys itself like this when it is “universalized” should
be judged unethical.
The other formulations of the categorical imperative – respect for people as
rational agents and treating people as ends in themselves are a bit simpler to understand.
They both imply that people, by virtue of their rationality, possess an intrinsic dignity. For
Kant, the ability to reason (rationality) is what separates humans from other animals. In
addition, it allows people (“rational agents”) the ability to determine their own fate. As
such, humans should never be used merely as means to an end – even “the common or
highest good,” but should be treated as ends in themselves. The utilitarian view that
sacrificing certain individuals or deceiving them even for the happiness of many others
would be wrong for Kant because that would be treating people as a means to an end and
would be disregarding their will as rational agents.
We can see that for Kant it is not the consequences but the quality of the motive or
will or intention which determines the ethical nature of an act. Kantians thus believe that
there are intrinsically good or bad actions, regardless of the consequences. In this view
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people have intrinsic rights over their own bodies and lives that medical research and
technology cannot disregard, even in the name of the greater good. In our previous example
of the doctor concealing the potentially harmful drug to his test subjects, Kant would say
this was wrong because we would be using these subjects only as means to an end and not
as an end in himself/herself.
It is not difficult to see how this system of ethics may also have problems. Suppose
we are living in Nazi occupied Europe and are hiding Jews from the Gestapo. What should
we do if they come to our door and demand to know whether we are hiding these people in
our home? According to the Kantian view, lying, even to save a life, would not be allowed
according to the first formulation of the categorical imperative.
This again, seems to violate our moral intuitions which tell us that it is a moral act to save
people from unjust persecution or death.
Despite these apparent failings, there is something that rings undeniably true about
Kant’s categorical imperatives. For one thing, Kant’s ethics offers a defense for individuals
and groups whose lives or welfare could be threatened “for the greater good” and asserts the
rights and dignity of the individual against threats by the majority.
4. Natural Law Theory
Adherents of natural law believe that morality is based on following the natural order of
things. This view implies that moral principles can be read in the tendencies of the natural
order. These include:
i. the desire of all living things for self-preservation,
ii. the desire of all living things for procreation and family life, and
iii. the inclination of human beings to reason and act according to natural principles.
These tendencies, observable in animals in nature, for example, are used to establish ethical
principles and duties such as: respect for life, protection of the family and respect for
rational autonomy. Under these moral principles, most natural law theorists would oppose,
for example, euthanasia which contradicts the principle of respect for human life. The same
would be true for abortion and any artificial interference in the process of human
reproduction and genetics. But disagreements abound, too.
A major problem in natural law theory is determining what is “natural”, especially
for human beings. Is killing more natural than helping each other? Is homosexuality
“natural” and therefore morally acceptable or is it “unnatural” and thus immoral?
Furthermore, modern medical technology is full of artificial (“non-natural”) aids to extend
life, relieve and manage pain and other purposes. How does a natural law perspective deal
with this? Is wearing glasses unnatural and therefore immoral? Finally, equating what is
natural with what is good is a common practice but it can sometimes wind up in some fairly
problematic conclusions. For example, if nature is, as some claim, a jungle in which only
the fittest survive, does that mean that this is how humans should also conduct themselves?
5. Contractarianism (Social Contract Theory) and Natural Rights
This theory imagines society, including government and laws, as if it were an agreement
between people. What would we all agree to if we could set up our own society? That is the
test of whether any act or policy is right or wrong according to this theory. The agreement,
called the social contract, would probably include whatever would help maintain life,
order, liberty, property of the signatories to the social contract.
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One of the earliest social contract theorists, Thomas Hobbes (1588-1679), proposed
that humans were at first in a “state of nature” with no laws or rules and were thus like in a
“war of all against all” in which each person’s life was “solitary, poore, nasty, brutish and
short”(Hobbes ch. 13). For their mutual benefit, says Hobbes, people agreed to establish
government and laws and live in society – the social contract. For Hobbes, the social
contract traded the original but insecure freedom people had in the “state of nature” for the
advantages living in society could bring, including laws, order and stability. Since Hobbes
saw people’s lives in the state of nature (before the social contract) as especially insecure,
his view was that the contract gave the king (or government) almost complete power over
the people. In other words, people had few rights under society against
government power. In exchange they had a safer and more stable society.
However, later writers, taking the same social contract idea, disagreed that people
had handed over almost all their freedom when agreeing to live in society. The British
philosopher John Locke (1632-1704) wrote that governments did not or should not have
complete power over individuals and could not take away the life, liberty and property of
people because these were “natural rights” that people had in “the state of nature” even
before the social contract and could not be taken or traded away even to form or enter
society. Today the idea that people have rights is very influential indeed. We find the idea
of rights in the US Declaration of Independence of 1776:
We hold these truths to be self-evident, that all men are created equal, that they are
endowed by their Creator with certain unalienable Rights, that among these Life,
Liberty and the pursuit of happiness.
We find the same idea in the Canadian Charter of Rights and Freedoms which lists
some of these rights in section 7, as mentioned above:
Everyone has the right to, life, liberty and the security of the person and the right not
to be deprived thereof except in accordance with the principles of fundamental
justice (“Canadian Charter of Rights and Freedoms”).
People today use “rights” language all the time. But there is a difference between
“legal rights” as put down in legal documents like the Canadian Charter and “moral rights”
which might not be in the law but may still influence people’s ethical views and actions.
During slavery, for example, abolitionists used the idea of “rights” to try to win freedom or
liberty for the slaves. At first this right of freedom was seen as a moral or ethical right. Only
later, when the abolitionists cause grew more powerful, was it transformed into a legal right
and slavery legally abolished. The same thing happened with women’s rights and now may
be happening with Gay rights here and elsewhere in the world.
Modern day contract theorists propose that the best way to establish whether an
action or policy is moral is to imagine what rules we would agree to for society if each
person could decide for himself or herself what these rules would be. To find the best rules
we would need to make them based on objective reason rather than on our own particular
interests or biases, as if we did not know what kind of careers and special interests we were
going to have. We would not know if we were going to be a beggar or a millionaire. By
following this procedure we could find ethical rules that would really be objective and
achieve the common good that we should live by. In reality, of course, we are all born into
an already existing society with all sorts of rules, ethical and legal principles already in
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place. But contractarianism asks us to pretend that’s not the case as a method to discovering
objective ethical rules or principles to live by.
Obviously, rules like those protecting people against murder, theft, slavery and such
would probably be accepted. Nobody would agree to join a society in which these things
were acceptable because you never know if you might not wind up as a victim of murder or
as a slave. But how would contractarianism deal with the issue of whether it is
ethical for you to cheat on an exam? Or about whether you should tell the truth to your
friend about his lousy artwork or be loyal or encouraging? How would it stand on issues
like abortion? Does the foetus have “a right to life” like other individuals in society or are
the mother’s rights of liberty more important? It may not be so easy to apply
contractarianism to these daily moral problems. Another major criticism is about the
make believe nature of social contract theory. Even social contract theorists admit the “state
of nature” probably never existed since humans have always lived in societies with rules.
Thus there probably never was a “social contract” and some go so far as saying the entire
idea of “natural rights” is also nonsense. The utilitarian philosopher, Jeremy Bentham, for
example, says the idea of natural rights is like “nonsense on stilts”. Despite this, social
contract theory remains, especially the influential idea of “rights”.
6. The ethic of care
Advocates of the ethic of care (sometimes also called feminist ethics) criticize the
general approach of the ethical theories we’ve just examined. They question the attempt to
establish universal and general moral laws covering all cases. They also criticize the
assumption these theories make that human society is like a battlefield between individuals
with competing interests and rights. The ethic of care stresses the uniqueness of each case
and the need for sensitivity to the specific needs of the unique individuals in each case,
rather than the construction of general theories and principles. A key principle it does
follow, however, stresses the importance of maintaining responsibilities and social
relationships rather than managing conflicting interests and rights. As in other approaches,
there are differences in how the ethic of care evaluates various cases. In the abortion
controversy, for example, some claim the ethic of care allows us to see that the central issue
is not in pitting the rights of the foetus against the rights of the mother but in showing a
concern for both and viewing them both as a single unit, precluding restriction of women’s
rights and her own sense of responsibility. Others however, using the same framework,
propose that law should impose a “duty of care” on pregnant women to protect a foetus.
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PART III: THE GROWTH OF MEDICINE & THE BIRTH OF
BIOETHICS
A. Beginnings
Since bioethics has become a branch of philosophy (philosophical ethics), one can
trace it back to the beginning of western philosophy in the 6th century BC in ancient Greece.
The Greek philosophers tried to understand the world around them by relying on fact and
reason. Even more specifically, some thinkers at that time began to try to explain health and
disease by the same means. The “father of medicine” in the West, Hippocrates (c.460-377
BC) was one of the earliest to approach illness and health in this way. For example, he
correctly interpreted epilepsy as a result of a brain anomaly rather than as possession by
demons as had previously been thought. Medicine, as a science, began at this point. It is
interesting that Hippocrates is also widely known for the famous Hippocratic Oath which
is one of the earliest examples of a code of ethics for the medical profession. Hippocrates
seemed to understand that doctors needed not just to have knowledge about their craft but
also needed to have that knowledge guided by ethical principles. After all, anyone who had
the power to heal also had the power to inflict harm. Thus was born the still influential
Hippocratic Oath and at the same time, the field of bioethics.
However, there was little development of bioethics beyond the Hippocratic Oath
until modern science and modern medicine began to make a serious impact on the lives of
people. Before the 19th century there was no understanding of germs and microbes, no
vaccination, limited hygiene, poor nutrition for much of the population and if seriously ill,
one was lucky to survive a visit from a doctor or a stay in the hospital, if these were
within reach in the first place. To make matters worse industrialization was crowding
people together in rapidly growing cities and creating even more difficult conditions for the
great numbers of impoverished and landless labourers who flocked there to search for work.
Serious outbreaks of infectious disease began to threaten even the more prosperous classes.
Bioethics rose when medical science began to make a substantial difference in the
life span and the quality of life of the average person because along with these benefits were
unforeseen drawbacks that we are now facing. But we should not forget that fancy new
machinery or technology is not the only factor here. At least as important were changes that
had little to do with medical science and much more with political and economic battles, as
we will see below. Furthermore, the beginning of modern bioethics owes much to events
that happened during World War II (1939-45) and the period immediately after,
sometimes described as the Cold War (especially 1950s to 70s).
These events also have less to do with medical or scientific breakthroughs and much
more with history, politics and economics. We begin with a look at the increasing impact of
medical knowledge and of social changes that dramatically changed the standard of living
of people in the western, richer countries of the world.
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B. The Increasing Impact and Power of Medicine & the Life Sciences
The average life span of an American male in 1900 was about 44-45 years old.
Today it is about 74-75 with another five years for the average female (“Ten Great Public
Health Achievements” 1481). Similar figures are found for most Western countries. In
Canada, life expectancy for a baby born in 2005 is about 80.4 years3. In less than a hundred
years, we have practically doubled the life expectancy of people in the rich countries of the
world. Equally important has been the lowering of the death rate due to various factors like
infectious diseases and malnutrition. How was this miraculous achievement made possible?
Three key elements are involved:
(i) the growth of scientific knowledge about the cause of disease and improved medical
technology this made possible.
(ii) increasing economic growth and productivity due partly to industrialization.
(iii) increasing power of ordinary citizens which led to improved conditions and to the use
of (i) and (ii) above for the benefit of a wider section of society.
Only point (i) is examined in this section.
One key element in extended life span is the growth in scientific understanding of
hygiene and sanitation and the recognition that infectious diseases were partly the result of
bacteria or germs. Improved hygiene in the growing cities, in childbirth and in surgical
operations also helped. Perhaps the most crucial factor was the initiatives that led to cleaner
water supplies and sewage disposal. Polluted and unhealthy water are key causes of
deadly infectious and non-infectious diseases, especially among children and infants. When
governments began massive and expensive programs to pump fresh water into every home,
it made a huge difference to the overall health of the people. Unfortunately, clean water
supply, including sewage disposal, is an expensive proposition and thus many of the poorer
countries of the world still suffer from the diseases due to this cause. Safer and healthier
working environments and improved housing conditions also contributed to improved
hygiene and sanitation and also raised the overall health of people. In combination with
large scale vaccination programs, this prevented the illness or death of millions of people.
Another key cause of this extended life span was improvement in nutrition. In
1900, most people simply didn’t eat enough or didn’t eat sufficiently nutritious food.
Thanks to increase in agricultural productivity, in wages and in transportation and
communication, safer, healthier and more abundant foods improved overall health. Both
improved sanitation and nutrition have eradicated a number of infectious diseases,
reduced infant mortality and helped extend life for most people in the developed world.
After World War II (1939-1945), more scientific advances also paved the way to
modern medicine. Most important were the development of antibiotics such as
penicillin, a major step in managing and eradicating bacterial infections like pneumonia,
syphilis, gonorrhea, diphtheria, scarlet fever and tuberculosis. One disease, smallpox,
3
This is an average between males and females. “Life expectancy hits 80.4 years: Statistics Canada,”
CBCnews.ca, http://www.cbc.ca/canada/story/2008/01/14/death-stats.html
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which had killed millions of people throughout history, has been completely eradicated. A
continuation of large-scale inoculation programs for diseases like polio have also all but
eliminated many of the dreaded diseases of the past – at least in the rich countries.
In the 1960s the adoption of all kinds of life-saving machinery such as the
respirator, the kidney dialysis machine, and, more recently, the adoption of various kinds
of diagnostic scanning tools from the CT scanner to ultrasound to the latest computerassisted MRI (Magnetic Resonance Imaging) systems have also made a profound impact
on diagnosis and treatment of illness and disease. Organ transplantation and other
techniques have prolonged the lives of many who would otherwise have died. Also
important has been the continued development of drugs of all sorts. These have allowed
people to manage illness, cope with pain, and otherwise lead more productive lives than
they otherwise would. A famous recent example is the drug combination called AZT (also
called the “cocktail”) which has dramatically changed the outlook of people suffering from
HIV and full blown AIDS. Again, however, most of the benefits of this discovery have
gone to people in the rich countries of the world.
Progress in Medical Science and Technology Creates New Dilemmas
Many of the technologies and advances mentioned above help to save lives and
relieve suffering, but they also created new previously unimaginable problems and ethical
dilemmas. For example, drugs and treatments to help alleviate suffering and disease have
sometimes caused terrible and unforeseen consequences in the people who have taken them
or their offspring. This was the case in the infamous thalidomide tragedy in which
pregnant mothers were offered pills to relieve “morning sickness” but which resulted in
serious birth defects in their children (“Thalidomide”). Human and animal
experimentation in the process of understanding disease and in creation or testing of some
of these drugs to counter disease has also sometimes erupted into serious ethical
controversy. The miracle of antibiotics has suffered a serious setback with the development
of antibiotic resistant bacteria that threaten a comeback of many diseases previously
thought conquered. Organ transplantation and dialysis has sparked debate about who gets
access to these and who doesn’t, as well as whether we should or should not allow payment
for the “gift” of a new organ. The ability to maintain life through the respirator and other
means has forced us to seek clearer definitions of death while the extension of life has given
rise to questions about the quality of life that is thereby extended, along with questions
about the ethics of assisted suicide and euthanasia. The high cost of many drugs,
treatments and medical technologies has raised issues of equal access to these treatments
and has put a strain on the public health care system in Canada and many other countries.
Such questions kept bioethicists busy for decades. And the continuing growth of medical
science and technology has kept bioethics busy right up to our own time.
C. The Biological Revolution
Most recently, a new wave of scientific advance in biology, genetics, and biological
technology (biotechnology) has resulted in what has been called the biological revolution
or genetic revolution. The manipulating of the genes of animals, plants and
microorganisms, called genetic engineering or recombinant DNA technology, is at the
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heart of this revolution. Aided by the vast new information gained by the Human
Genome Project, a largely U.S. government sponsored multi-billion dollar project to
map the entire human genetic code. The HGP promises to assist the science of genetics in
opening new doors to the prevention and treatment of genetic and partially genetic illnesses.
Already, genetic testing allows us to peer into our own genetic makeup and the genetic
makeup of the fetus (called prenatal diagnostics) to search for genetic or chromosomal
diseases, such as Down’s Syndrome, Huntington’s, Tay Sachs or genetic vulnerabilities,
such as predisposition to certain forms of cancer. The new techniques of gene therapy,
promise to one day remove or alter genes responsible for these diseases or vulnerabilities.
Meanwhile, knowledge of the chemical structure of genes allows for the creation of new
drugs and medications of all sorts that are more powerful, more varied, more specialized,
more effective and more abundant than ever before.
Stem cell research and research on fetal and embryonic tissue is yet another
example of the powerful possibilities of biological technology, this time holding the
promise of regenerating diseased organs or tissues by the use of cells derived from the
tissues of fetuses and embryos. Perhaps stem cell research illustrates most clearly both
the promise and the obvious ethical problems that modern medicine creates. In medicine,
new knowledge and techniques have allowed doctors to better manage pain, extend or
maintain life and find new treatments and therapies for previously untreatable conditions
but this has not been purchased at a cheap price either financially or ethically.
But the power of genetic manipulation extends far beyond medicine and human health or
disease. The biotechnology industry seeks to multiply the production of all types of animals
and crops and increase the milk, meat and dairy from the animals we raise through
genetically modified organisms (GMOs) and genetically modified foods (GMFs). New
kinds of pesticides and herbicides and even new species have been created in the continued
effort to improve productivity and increase profits. Cloning of animals,
including humans, is only one example of the continuing spectacular advance not just in our
ability to control disease but to control life itself – all life – at the most basic, genetic level.
The genetic altering of foods and living products may have long term harmful
consequences for the animals and organisms concerned, for the environment as a whole and
for humans who consume or are exposed to these products. At the same time, the
commercial development of genetic “products” has led to the patenting of certain genetic
lines and even whole organisms in the United States, raising the issue of whether owning
the rights to living things is morally acceptable. The diagnosis of genetic diseases in adults
presents us with the painful dilemma of whether we should inform people that they have
these conditions, especially when no effective treatment exists. Widespread knowledge of
our genetic makeup may increase the likelihood of a new form of genetic
discrimination where employers, for example, refuse to hire us because of presumed
genetic vulnerabilities to certain diseases and presumed genetic suitability for certain kinds
of jobs. Diagnosis of the genetic conditions of the unborn (prenatal diagnosis) raises new
questions about selective abortion, sex-selection, disability and the value or quality of life.
Stem cell and fetal tissue research have also poured new fuel on the age- old abortion
debate. The genetic engineering techniques used in biotechnology may also soon allow us
to alter the genetic makeup of human beings. The same gene therapy techniques
scientists use to replace genes responsible for genetic diseases by normally functioning ones
may allow us to genetically “custom make” our children to have
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features and traits we consider desirable. This “playing of God” as some people call it, or
the replacing of nature by human will might be one of the most serious and disturbing long
term consequences of the new genetic technology. In this case, we are increasingly forced
to ask what makes us human and what is freedom if someone else is able to design us as
he/she desires? It would appear that for every advance there are serious harmful or
potentially harmful “side effects”, to say the least. This should make clear why ethical
knowledge and debate are so urgently needed today.
As we can see, almost all medical and technological breakthrough come with
unforeseen and unintended, sometimes harmful effects. Today we also need to include the
harmful effect not just on people but on the environment and on other animals and plants.
That is one important lesson we need to keep in mind as we move further into the
21st century.
Finally, bioethics is sometimes closely associated with environmental ethics,
which examines the ethical obligations we have towards our environment. Clearly, the
environment is one of the key issues of our time and is another example of how
technological change brings with it unforeseen problems and controversies. Canada has
been in the international spotlight recently in terms of environmental policy. We have not
lived up to the engagements signed during the Kyoto Conference in 1997 to reduce Green
House gases. Indeed, the development of the Alberta Tar Sands project by various
governments and industry has raised a storm of controversy raising a question over whether
tar sands mining is environmentally safe and ethically acceptable.
D. Human Experimentation, Nuremberg Code & Foundation of Bioethics
The many scientific and medical developments alluded to above and the great number of
ethical dilemmas they give rise to, hopefully provides part of the background for
understanding the emergence of bioethics as a distinct specialty in the post war period.
Most significant to the birth of bioethics was the issue of unethical human experimentation,
especially as conducted in World War II but also, as will be seen, which continued on in the
USA, Canada and other countries even after the war.
World War II (1939-45) was the most destructive war in human history, resulting
in the deaths of anywhere from about 50 to 65 million people, most of whom were
civilians4. Though science and technology had helped to extend human life, the war gave
humanity a stark lesson on the potentially destructive application of modern science and
technology when divorced from ethical constraints. Most instructive in this
regard were the system of concentration and death camps built and maintained by the
German Nazi regime throughout occupied Europe in which about 12 million were killed by
shooting, poison gas, starvation, exhaustion or other means. This includes the figure of
about 6 million Jews killed either in concentration or death camps or elsewhere in what is
called the Holocaust (or Shoa in Hebrew), 2-3 million Soviet prisoners of war (PoWs), and
large numbers of Roma (“Gypsies”), homosexuals, and others.
When the war ended, some of the leadership of the Axis Powers were judged in an
extraordinary series of trials organized by the Allied powers, the victors in the war, with
4
Matthew White estimates 65.6 million “Source List and Detailed Death Tolls for the
Primary
Megadeaths of the Twentieth Century,” accessed 13 December, 2012, http://necrometrics.com/20c5m.htm
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the United States leading the initiative. In Europe, the trials were held in the German town
of Nuremberg, once the site of many Nazi rallies. One set of these Nuremberg Trials were
directed at the political and military leadership and another set dealt with other actors,
including doctors. “The Doctor’s Trials” put some of the leading German doctors and
scientists involved in inhumane experiments on the dock. The Nuremberg Trials were the
first such trials in history and although some view them as propaganda exercises, it is
important to recall that to the judges themselves, after so many years of horrific violence on
an unprecedented scale, they represented an attempt to return to the
values of “civilization”. As Justice Robert Jackson (1892-1954) so eloquently put it:
the wrongs which we seek to condemn and punish have been so calculated, so
malignant, and so devastating, that civilisation cannot tolerate their being ignored,
because it cannot survive their being repeated.
The “wrongs” Jackson refers to are mostly Nazi experiments conducted on
unwilling concentration camp inmates. They included high-altitude experiments where
inmates were placed in low-pressure chambers, freezing experiments, experiments
involving injecting inmates with various diseases, bone-grafting experiments, exposing
prisoners to phosgene and mustard gas, experiments on twins, experiments using various
methods to sterilize inmates, and many others (“Nazi Medical Experiments”). The
Doctor’s Trial resulted in the sentencing of some of these Nazi doctors to death by hanging
or imprisonment but also to the formulation of the Nuremberg Code, a 10 point code of
ethics outlining the rights of research subjects in human experiments. Along with the
United Nations Universal Declaration of Human Rights5, the Nuremberg Code,
especially the stress on informed consent, became a cornerstone of international law,
human rights and bioethics in the post war world (Annas). Though some writers disagree
(see Ghooi), The Nuremberg Code has been called the most important bioethical document
since the Hippocratic Oath.
Unfortunately, the Nuremberg Code did not prevent further unethical experiments
after the war. In a very influential article entitled “Ethics and Clinical Research” the
American anesthesiologist Dr. Henry K. Beecher (1904-1976) outlined 22 examples of
ethically questionable experiments conducted after the war. Some leading to death and
lasting injury. Many writers believe that along with the Nuremberg Code, Beecher’s article
marks the beginning of modern bioethics in America. It led not only to the drafting of
stricter ethical controls in the form of the Belmont Report in the USA and the World
Medical Association’s Declaration of Helsinki but the beginning of bioethics as a modern
discipline taught in colleges and universities throughout the United States and the western
world. Books and publications devoted to the new field multiplied throughout the 1970s
and up to our time. New institutions devoted to medical ethics and bioethics also sprang up
by the late 1960s and 1970s, like the Hastings Center (founded in 1969) and the Kennedy
Institute of Ethics (founded 1971). Presidents Clinton and Bush (Jr.) also formed Bioethics
councils to engender debate and advise them on how to address the many bioethical issues
opened up by new medical and genetic technology. However, though modern bioethics
contributed to opening of ethical debate in institutions of higher learning and may have led
to greater respect for experimental subjects and patients alike, it did not end or prevent all
unethical experiments and treatments.
5
Authored in part by the disabled Canadian lawyer, John Peters Humphrey (1905-95)
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Moreover, a danger emerged from the growth of bioethics as an academic specialty
that debate and policies would be dominated by experts and specialists and thus shut out the
general public. In a democratic society that is supposed to reflect the informed will of the
people, this would indeed be an unfortunate development.
Another danger is that bioethics could become so narrowly defined that crucial and
controversial questions would be left out, especially if these were politically sensitive. Thus
we note that few bioethical textbooks deal with the issue of torture and
extraordinary rendition in the wake of 9/11 and the “war on terror” (see below). These are
sometimes simply not seen as “bioethical issues” and thus not mentioned. Instead there is a
focus on the important, though well worn themes of abortion, euthanasia, and the ethical
debates arising from the new genetic technology. At the cost of becoming an established
discipline, bioethics may be in danger of losing its critical edge and of failing to challenge
the power structures that allowed abuses like those detailed at Nuremberg or those that may
have occurred much more recently in the “war against terror”.
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PART IV: BIOETHICS: DEFINITION & KEY ETHICAL
PRINCIPLES
A. Definition of Bioethics
We are now ready to understand how bioethics fits into the wider tradition of philosophical
ethics.
Bioethics is a field of study dealing with the ethical implications of biological and medical
practice, research and technology. A compound word coined in the late 1970s, bioethics
includes a study of


biology, the science of living things, including human and non-human life and the
environment that sustains it
ethics, the study dealing with moral values, what is good or bad and with moral duty
and obligation
Bioethics has also been called “biomedical ethics” and “medical ethics”, though it deals
with a greater range of issues than the latter. The word “biology” (from the Greek root bios
meaning “life” or “living”) here includes the study of, experimentation on and use of living
beings, whether human or not. Biology also includes the important fields of medicine and
genetics. We have already mentioned and defined the term “ethics”. Although bioethics in
some form has been around for a long time, the word itself was invented in 1971 by an
American physician V.R Potter in his book Bioethics: Bridge to the Future, stating:
I... propose the term Bioethics in order to emphasize the two most important
ingredients in achieving the new wisdom that is so desperately needed: biological
knowledge and human values (Potter 3)
The goal of bioethics is, as Potter says, to apply ethical thinking or “wisdom” and
moral values to the dilemmas, questions and issues raised by the many developments in the
fields of biological and medical science. The urgency of Potter’s plea to “achieve the new
wisdom that is so desperately needed” is partly due to the tremendous advances in our
scientific knowledge of what causes disease and what accounts for well being in humans
and other living things. Most important have been the advances made in the various fields
of biology, medicine and medical technology, especially in the last century. These have
proved tremendously beneficial in many ways but have also had unforeseen and often very
harmful consequences, forcing us to ask the bioethical kinds of questions mentioned above
and to make difficult and often painful decisions.
Since the biological and medical fields often deal with the well being, suffering and
life and death of human beings and other organisms, it should be clear that ethical concerns
will necessarily be connected to these life sciences in some form. For example: who decides
who gets life-saving treatment? On what basis is that decision made? What kinds of
treatments or procedures are justified on humans or other animals in the name of science or
for other purposes? Should we extend the life of everyone as much as possible even if that
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means unbearable pain and suffering? Should we alter people’s genetic codes to cure
disease or even to improve one’s intelligence or looks? Should we allow cloning of humans
or animals? What are our ethical obligations, if any, toward non-human animals? What of
our obligations towards the natural environment? These and many
other questions require ethical reasoning and this is the job of bioethics. Part of the goal of
bioethics is to help us make both ethical and logical decisions on such questions but as we
will see, it also can help us look far more deeply and critically at the world, the
society and the kind of people we have become or want to become.
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B. Key Ethical Principles in Bioethics
Bioethics writers use many of the ethical theories discussed above. But they also use ethical
principles. Many of these are common to philosophical ethics in general but some are
especially important or relevant to bioethical concerns. Below we examine seven of the
most important ethical principles mentioned in a Report prepared by the Royal
Commission on the New Reproductive Technologies (Kymlicka, RCNRT, 16) in 1989
and relevant to bioethics. The (RCNRT) was given the mandate of investigating the impact
of some of the New Reproductive Technologies on Canadian society and to recommend
policies to the government to minimize some of their possible negative consequences. Note
that many of these principles were meant to respond to development in the late 1980s and
early 1990s when In Vitro Fertilization (i.e., “test-tube babies”) and surrogate
motherhood were some of the most prominent issues. Today, many new developments,
such as cloning and genetic engineering of people, plants and animals, for example, would
also need to be addressed. Furthermore, we are dealing here with a Canadian commission
that is attempting to establish ethical guidelines in the context of a health system that is
publicly funded and accessible to all – unlike what we find in the United States. Despite
this, many of the ethical principles remain relevant to the present time and continue to be
used both here, in the US and in other countries.
Provide a one sentence definition of each:

individual autonomy:

justice:

equality:

beneficence:

non-malfeasance:

respect for human life: _

accountability:
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PART V: BIOETHICAL ISSUES
This section examines some of the bioethical issues we will be covering in this class. It is
intended only to give a background to help in understanding further readings and
stimulating class discussion and debate. The issues covered deal with human
experimentation and torture, health care, euthanasia, the biological revolution and the
Alberta Tar Sands project.
A. Issues #1 & 2: Human Experimentation & Torture
1. Cold War Background: A Canadian Cold War Connection
As mentioned, the issue of unethical human experiments conducted during the Nazi
period and prosecuted during the Nuremberg trials following the war led to the Nuremberg
Code and was a major contributor to the formation of modern bioethics. But the story does
not end there.
The post war period featured an ideological rivalry between the USA and the USSR
and their allies for political influence throughout the world called the Cold War. Fear and
paranoia existed on both sides that one side would crush the other. In America, anticommunism reached a peak in trials in the 50s against hundreds of people accused of being
communist and possible agents of the USSR. The trials were led by Senator
Joseph McCarthy (1908-1957). In addition, trials against many people in the film industry
were conducted by the House Un-American Activities Committee. The trials are now
considered like “witch hunts” that ruined the lives of many American politicians, activists,
artists and scientists. At the same time, paranoia and fears about possible “brainwashing”
are also reflected in movies like The Manchurian Candidate (1962), remade but with
much different plot line reflecting a different time in 2004.
At the same time, the Korean War in the 50s raged between North Korea,
supported by Communist China and the USSR against South Korea, supported by the US,
Canada and other western nations and the UN. When some American soldiers were
caught by the communists and denounced their own government, even when they returned
home, American authorities feared they had been “brainwashed” and thus
decided to launch their own brainwashing program, entitled MK-ULTRA, directed partly
by the CIA (Central Intelligence Agency)6.
2. Dr. Ewan Cameron’s Experiments at the Allan Memorial in Montreal
Ewan Cameron (1901-1967) was a psychiatrist, observer at Nuremberg Trials, and
former head of the American Psychiatric Association conducted experiments on
psychiatric patients at McGill University’s Allan Memorial Institute in the hopes of
curing their mental illnesses in the 1950s and early 60s.
Cameron’s experiments involved sleep deprivation and sleep inducement, intake
of massive doses of hallucinogenic drugs like LSD, and repeated high doses of
6
Author Colin A. Ross disagrees, claiming the US “brainwashing” program started before this.
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electroshock therapy (ECT). Cameron’s idea was that he could wipe out past behaviour
patterns that supposedly created the mental illness (he called this “de-patterning”) and then
replace these with “good patterns” via “psychic driving” through constantly repeated taped
messages both during sleep and in waking hours.
With CIA funding from 1957 to 1963, Dr. Cameron had used approximately a
hundred patients as involuntary subjects to test a three-stage method for “brain
washing” or “depatterning”—first, a drug-induced coma, spiked with LSD for up to
eighty-six days; next, extreme electro-shock treatment three times daily for thirty
days; and, finally, a football helmet clamped to the head with a looped tape
repeating, up to a half-million times, messages such as “my mother hates me”
(McCoy, 408)19
Unfortunately, he succeeded only in destroying the complete memories and
therefore the identities of many of his patients. Many lost all memory of their children,
husbands, past jobs, past life and even how to play guitar. He was never able to replace the
“bad behaviour patterns” with “good ones”.
His patients did not know and were never told they were taking part in experimental
procedures and did not sign their consent to these. Despite these harmful results, the CIA
thought Ewan Cameron’s work in Montreal perfect for their MK- ULTRA program and
funded his experiments under cover of a front organization called the Society for Human
Ecology.
3. Dr. D.O. Hebb’s Sensory Deprivation Experiments at McGill University
Donald O. Hebb (1904-1985) was another brilliant Canadian scientist who, like Cameron,
also worked under Dr. Wilder Penfield at the Montreal Neurological Institute in the
1930s. He was appointed professor in the psychology department at McGill in 1947 where
he continued work on understanding the physiology of the brain and was also elected
president of the American Psychological Association in 1960. His scientific work,
including his book, The Organization of Behaviour (1949), were major advances in the
field of brain and behavioural science.
Hebb’s sensory deprivation experiments sought to block out all sensory inputs
from volunteer experimental subjects such that they were unable to see, hear, touch or smell
for extended periods of time. These experiments, Hebb states, originated in the forced
confessions produced by the Soviet and Chinese communist governments during the Cold
War. Some thought that the Russians and Chinese had succeeded in finding the method of
“brainwashing” people.
The work that we have done at McGill University began, actually, with the problem
of brainwashing. We were not permitted to say so in the first publishing.... The chief
impetus, of course, was the dismay at the kind of “confessions” being produced at
the Russian Communist trials. “Brainwashing” was a term that came a little later,
applied to Chinese procedures. We did not know what the Russian procedures were,
but it seemed that they were producing some peculiar changes of attitude. How?
One possible factor was perceptual isolation and we concentrated on that. (“Donald.
O. Hebb”)
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Subjects were put in isolation chambers with bandages over their eyes, hands and
other body parts. Later, some were put in what are now called floatation tanks at body
temperature. Sometimes “white noise” was played via headphones. The results surprised
even Hebb. Subjects became quite agitated and anxious within a fairly short time. They
began experiencing hallucinations and many struggled to break out of their confinement.
One subject suffered prolonged mental illness and, according to one author, there was a
serious risk of lasting psychological damage. “It scared the hell out of us,” Hebb said later,
“to see how completely dependent the mind is on a close connection with the ordinary
sensory environment, and how disorganizing to be cut off from that support”(McCoy, 409).
Despite these risks, and despite the apparent violations of the Hippocratic Oath and the
Nuremberg Code both Cameron’s and Hebb’s experiments represented, they continued well
into the 1960s.
4. From Defensive Theory to Offensive Practice
Initially, the CIA claimed that they supported both Cameron’s and Hebb’s work to
gain knowledge that soldiers or others could use to defend themselves against brainwashing
if captured in war or other circumstances. But these supposedly defensive purposes could
and were fairly rapidly transformed into offensive ones. The CIA applied the knowledge
gained from these experiments in perfecting interrogation techniques against real or
perceived enemies. Some of this is clearly evident in the agency’s now declassified
publication entitled “Kubark”. Called a “torture manual” by some and summarizing some
of the work above and mentioning “experiments conducted at McGill University,” Kubark
states that sensory deprivation works since “the calculated provision of stimuli during
interrogation tends to make the regressed subject view the interrogator as a father-figure . . .
strengthening . . . the subject’s tendencies toward compliance” (KUBARK, 87-90). This
government agency had used the techniques developed to understand the mind and to
provide therapies to patients and used them instead for the interrogation and manipulation
of those they deemed enemies.
5. 9/11 and Beyond
The story continues into our own time. The events of 9/11 ignited dramatic changes on the
international scene. The United States retaliated against the terrorist attacks on the World
Trade Center, the Pentagon and other sites by launching a “war on terrorism”. This
included the invasion of Iraq and the ousting of its leader Saddam Hussein, a war in
Afghanistan followed by the ousting of the Taliban regime there and a manhunt for
Osama bin Laden. The latter was found and killed by American Navy Seals in May
2012.
On another front, many suspected terrorists or terrorist supporters were captured and
interrogated by US authorities. Some were sent to other countries for interrogation – often
with the knowledge that these prisoners would be tortured. This practice was called
“extraordinary rendition” and Canada as well as Britain and other countries took part in
the practice. In addition, the CIA operated what are called black sites in various countries
where prisoners were allegedly tortured (Priest). Those not sent elsewhere to face torture
were sent to the US naval base at Guantánamo Bay, Cuba. There, CIA interrogators and
others utilized many of the techniques outlined in the Kubark manual and derived partly
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from Cameron’s and Hebb’s experiments. Techniques of sensory deprivation, including
immediate “bagging” of individuals” are well known from countless photographs. But the
technique was carried further in the cells of the prisoners. Sleep deprivation and use of
disorienting drugs as well as other techniques familiar from the Canadian research and other
forms of psychological and physical coercion were used. Some of the same techniques
emerged again with photographic clarity when the Abu Ghraib prisoner abuse scandal
broke in 2004.
Critics vehemently opposed these practices which they claimed constituted torture
and thus violated the UN Convention Against Torture as well as the Geneva
Conventions designed to protect prisoners of war, to which the US was a signatory.
The US administration under George W. Bush countered that the prisoners were not
prisoners of war but “unlawful enemy combatants” and as such were not covered by the
Geneva Conventions. The use of torture was denied and redefined to fit in with practices
called “enhanced interrogations”. Most controversial was the practice of waterboarding.
According to Senator John McCain, who was himself detained and tortured for 5 years
during the Vietnam War, during World War II, the US hanged Japanese officers for
waterboarding (“McCain: Japanese Hanged For Waterboarding ”) and other torture yet
under the Bush presidency it was now seen as an acceptable part of “enhanced
interrogation” and not considered torture.
6. 9/11 and Beyond: Canadian Involvement
Once again, the Canadian government was deeply involved in some of these events.
A new category of crimes may now fall under the provision of security certificates
whereby non-citizens can be held indefinitely and deported. Canada has also participated in
extraordinary renditions whereby suspected security threats have been sent or diverted to
other countries where they have been tortured for months or years. The Maher Arrar case
is one of many which achieved international notoriety.
Omar Khadr is a Canadian who was wounded and captured in a small battle in a
village in Afghanistan and sent to Guantanamo Bay. He was 15 years old at the time.
Unlike the prisoners there from other western countries, the Canadian government did not
seek to extradite him from the infamous prison where he claims he was tortured. His
lawyers argued that he should not have been imprisoned under the UN conventions banning
prosecution of child soldiers. After 8 years at Guantanamo and a series of legal battles that
went all the way to the Canadian Supreme Court, Khadr was repatriated back to Canada
where he is serving the remainder of his sentence.
Canada has been condemned by the United Nations and Human rights groups for the
Security Certificates as well as its involvement in extraordinary renditions and for refusal to
seek extradition in the Omar Khadr case. There are unfortunately many other examples of
questionable conduct by our government in the “war on terror” and it is therefore important
for every citizen, regardless of the final evaluation he or she comes to, to know what is
being done in the name of national security.
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B. Issue #3: Euthanasia
1. Nazi Germany and the “Action T4 Program”
Euthanasia was not a major issue in most societies before the establishment of the
Judeo-Christian tradition. In ancient Greece the Hippocratic Oath forbade providing a
“deadly drug to anybody who asked for it, nor will I make a suggestion to this effect” and
this prohibition against killing was taken up by Christianity and matched its own views on
the sanctity of human life and in favour of caring for the weak or ill. In more recent times,
however, like human experimentation, euthanasia also has a dark history tainted by the
Nazi past. The Nazi euthanasia program – also called Aktion T4 – targeted residents of
institutions and hospitals caring for the mentally disabled and psychiatric patients. In
October of 1939, Hitler signed a decree enabling doctors to grant “mercy death” to patients
judged “incurable”. According to Karl Brandt, Hitler’s personal physician and others, Hitler
had wanted to do this earlier but understood that public opinion would be against it. The
program could be more easily implemented during time of war and this is what Hitler did.
He designated Karl Brandt along with Reichsleiter Philipp Bouler as responsible for the
initiative (“Action T4”). Medical staff in hospitals and institutions for the physically or
mentally disabled were obliged to register all patients who were deemed “incurable” or,
represented what Nazi ideology called “Life unworthy of life” (German, lebensunwerten
Lebens).
The program began with the killing of children under three with “serious hereditary
diseases” including “suspected idiocy,” Down syndrome, and those born with deformities
of all kinds. At first consent was sought from parents and legal guardians, but this was
couched in euphemisms that their children would be sent “Special Sections treatment
centers” to receive better care. These centers included psychiatric or care facilities specially
modified for the killing and disposing of bodies. Once there the children would be quickly
assessed and given lethal injections. Parents were told their loved ones had died of
pneumonia or other illness. When war broke out the program was
extended to include older children and those with no disability but who were troublesome
or juvenile delinquents. Jewish children were also rounded up. Eventually, the program
was expanded again to include adults, areas outside of Germany, and more conditions,
such as “epilepsy, Huntington’s Chorea, advanced syphilis…” and others were included. In
addition, the program began to utilize improved methods of killing using carbon monoxide
gas for more efficient and quicker results, first utilized in 1940. The killings were all
conducted and supervised by doctors and brain samples of the deceased were sent to
research centers. According to various authors, this was to maintain the idea that
these were medical measures rather than cold blooded murder. In all about 70, 273 people
were killed under this program (“Action T4”).
Though the program was clouded in secrecy, it was impossible to hide what was
happening for very long. Thousands of people were involved in the carrying out of the
program. Parents soon discovered that they had been lied to and that their children had
been killed. Significantly, serious opposition, especially among Catholic Germans and
Austrians developed. So much so, that Hitler decided to end the program in 1941. But the
killings continued, though at a less rapid pace.
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At the Nuremberg Trials some of the doctors responsible, including Brandt were
executed or imprisoned for their part in the program. Others killed themselves or fled.
Today, what happened in Nazi Germany, casts a dark shadow over discussion of
euthanasia. Despite this, support for euthanasia in specific circumstances has grown among
medical professionals and the general public and some countries and jurisdictions have
enacted laws that permit the killing of those in terminal stages of illness with their consent.
Though these measures are often controversial they do not come close to approaching the
cruelty and inhumanity of Nazi euthanasia program.
2. What is Euthanasia?
It should be stressed that the word “euthanasia” actually may not properly describe
the actions carried out in the Nazi T4 program described above. The word euthanasia is a
Greek compound word meaning “good death”. While some people may object that death
can never be good, we need to distinguish as clearly as possible between what the Nazis
did in their T4 program and other mass killings which is murder and euthanasia which
may be killing but not necessarily murder. Murder involves killing someone against his or
her will7 while the advocates of euthanasia today would insist that “true” euthanasia must
be at the request of the person who wishes to die. One philosopher includes the following
criteria to define “true” euthanasia”:
1. The death is requested by and is the genuine will of the person who wishes to die.
2. The death is for the good of the person who wishes to die and not for “the greater good”
of the country, family or anyone else.
3. The death is to relieve pain and suffering that is not treatable in any other way
4. The death is requested by a person who is already facing a terminal illness.
Clearly, this was not the case in Nazi Germany where people were killed against their will,
were not suffering pain or facing any terminal illness. They were killed – murdered
– for the supposed “good of the country” rather than for their own good. Unfortunately, we
continue to find questionable definitions of euthanasia even today. For example, Philippa
Foot mentions the Oxford English Dictionary’s definition “a quick and easy death” (Foot,
85-112). The definition leaves out some of the crucial points mentioned above, such as that
the death must be for the good of the person and his or her will. Similarly, Quebec’s Dying
with Dignity Report defines euthanasia as “An act that involves deliberately causing the
death of another person to put an end to that person’s suffering” (Dying with Dignity
Report, 18). This also leaves out the consent and other points mentioned above. Moreover
the Commission sought to avoid the word “euthanasia” altogether because it is
“emotionally charged” and “does not evoke the idea of support, which is central to our
proposal” (Ibid., 76)
Today’s euthanasia debate rages in many countries but almost all proponents of
euthanasia have at least some of these crucial criteria which differentiates today’s
euthanasia debate from what occurred in the past. The issue has become especially pressing
since the war because medical technology has continued to develop and provided the ability
to extend life but not always the “quality of life”. Advocates point to the prospect of living
7
Soldiers killing enemy soldiers in battle also be an exception to this as well and not considered murder.
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for extended periods with pain or with diminished physical and intellectual capacity and
claim that “genuine euthanasia” is born of compassion and respect for the autonomy and
will of the person affected.
That does not mean there is no cause for concern. Critics contend that even this
more humane euthanasia contains dangers. One of these is fear of the “slippery slope”.
This is the idea that accepting or legalizing euthanasia even for the most extreme or
exceptional cases will lead inevitably and uncontrollably to an expansion of the practice
such that many more will die and be killed than originally intended. This “snowball” effect
or slippery slope is in fact what happened in Nazi Germany. Some may thus agree with
euthanasia in principle but would be against enshrining this in law due to fears of a slippery
slope.
Others point out that since doctors would be the ones carrying out the killing, it
would represent a direct reversal of their essential mission and role as healers, doing
irreparable harm to the profession. Moreover, they argue, some patients would be hesitant
or even fearful of their doctors if euthanasia became a legal and accepted “treatment” (Kass
25-46).
A distinction is often made between “letting die” and “killing” also called “passive
euthanasia” and “active euthanasia”, respectively. The first means not taking
extraordinary steps to stop someone suffering from a terminal illness from dying. Thus a
patient suffering from inoperable terminal and painful cancer and who has only a few
months to live may request that his life not be extended through “extraordinary
measures” and be “allowed to die”. Passive euthanasia would mean that no drugs or other
means are used to extend this person’s life so that the disease takes its course and ends his
or her life. In active euthanasia, on the other hand, drugs or other means are used that causes
the patient’s death. An important moral difference is thus drawn between omission (not
doing something) and commission (doing something). This distinction, however, is rejected
by some philosophers as irrelevant, illogical and unethical (Rachels 78-80). Though it is
not often called “passive euthanasia,” anymore, “letting die” is common practice today
while “active euthanasia” remains prohibited and punishable by law in most countries (see
exceptions below). As one witness stated before the Canadian Senate:
Withholding or withdrawing life-saving medical care, "pulling the plug",
used to be called "passive euthanasia". However, as you reread the briefs of many of
my other colleagues, you will see that none of them still uses the term “euthanasia"
for these very widespread social practices. Indeed, tens of thousands of Canadians
die every year by what would have been called "passive euthanasia" and what would
have been condemned by church groups and by individuals as an alarming,
dangerous, negative development as recently as 12, 15 years ago. (Professor Arthur
Schafer, testimony to “The Special Senate Committee on Euthanasia and Assisted
Suicide Of Life and Death - Final Report June 1995”).
Advocates of euthanasia claim the distinction between active and passive euthanasia is
unjustified and the battle in most jurisdictions (including Canada and Quebec) is about
whether or not we should allow active euthanasia.
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3. Euthanasia in the Netherlands
The Netherlands was one of the first countries to permit active euthanasia in post
war period with the passage of the Euthanasia Act in 2002. The law stipulated 4 criteria for
granting a euthanasia request:
1. The patient’s request is voluntary and well-considered;
2. The patient’s suffering is unbearable and hopeless;
3. The patient is informed about his situation and prospects;
4. There are no reasonable alternatives. Further,
5. Another independent physician should be consulted; and
6. The termination of life should be performed with due medical care and attention.36
Between 1990 and 2001, there was an appreciable growth in the practice of euthanasia, with
cases of death from this cause growing from 1.7% (1990) to 2.4% (1995) to 2.6% (2001).
This fueled fears that the “slippery slope” was taking hold in the Netherlands. However,
“This trend reversed in 2005, when 1.7% of all deaths were the result of euthanasia
(approximately 2,300 cases)” (Rietjens, 273-274). But the slippery slope may still be there
after all, in a different form. The Dutch courts began to interpret “unbearable suffering” as
including not just physical ailments but psychological ones as well, as for example
“severe and refractory depression”. Some authors are opposed to euthanasia in the case of
psychological conditions like depression since these are treatable. But this development
does seem to point to problems in defining exactly what “unbearable suffering” means, who
should determine this and how far we should go in favouring choice or autonomy over
respect for life.
Scholars are divided over the impact of legalization but it is clear that the trend is
towards more countries following suit. Already Belgium and Luxemburg have enacted laws
legalizing euthanasia. The same is true of states of Oregon, Washington and Montana in the
USA. Canada now also has a province with legalized active euthanasia: Quebec.
4. Euthanasia in Canada
With the exceptions mentioned above, in many countries, euthanasia and physician assisted
suicide remains illegal. Part of the reason for this is due to the influence of the JudeoChristian tradition which, unlike the ancient Greek and Roman societies, viewed suicide
and euthanasia as a violation of the will of God and of the sanctity of human life principle.
However, not all opponents of euthanasia today invoke these religious reasons and some
provided philosophical arguments instead of religious ones to oppose the legalization of
euthanasia.
In Canada, though suicide is no longer illegal, under section 14 of the Criminal
Code of Canada:
No person is entitled to consent to have death inflicted on him, and such consent
does not affect the criminal responsibility of any person by whom death may be
inflicted on the person by whom consent is given. (Quoted in Tiedemann and
Valiquet)
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This means that helping someone to end their life is a crime even if that someone consents
to it. Section 241 spells this out more explicitly:
241. Every one who
1. counsels a person to commit suicide, or
2. aids or abets a person to commit suicide, whether suicide ensues or not, is guilty
of an indictable offence and liable to imprisonment for a term not exceeding
fourteen years (Ibid.).
These provisions of the Criminal Code were challenged, however, in a number of famous
legal cases, including that of Sue Rodriguez, a Victoria BC woman who was diagnosed
with ALS (Amyotrophic Lateral Sclerosis, also called Lou Gehrig Disease) in 1991. She
was 41 years old at the time. Knowing the degenerative disease would progressively
incapacitate her before finally killing her, she fought in the courts for the right to seek
assistance in her death when she felt the time was right. Against the Criminal Code sections
14 and 241, she invoked section 7 and 12 of the Canadian Charter of Rights and
Freedoms. Section 7 guarantees that
“everyone has the right to life, liberty and security of the person”
while section 12 states that
“Everyone has the right not to be subjected to any cruel and unusual treatment or
punishment.”
Her argument was that the prohibition against assisted suicide denied her right to
“liberty” and “security of the person” under section 7 of the Charter. The latter was
interpreted to include the principle of personal autonomy or “the right to make choices
concerning one’s own body…” (Smith). She also contended that forbidding suicide would
amount to cruel and unusual treatment since “it forces her to endure a prolonged period
of suffering until her natural death occurs or requires her to end her life before she wishes
so that she can do so without assistance.” (Ibid.). Finally she argued that making her suicide
illegal violated section 15 of the Charter which states that
Every individual is equal before and under the law and has the right to the equal
protection and equal benefit of the law without discrimination and, in particular,
without discrimination based on race, national or ethnic origin, colour, religion, sex,
age or mental or physical disability. (Quoted in Smith, Ibid.).
Since able bodied people can choose to commit suicide without assistance and without
penalty, section 241 of the Criminal Code discriminates against disabled people who are
unable to do so without assistance.
Another important case that once again triggered debate on the legalization of
euthanasia in Canada involved that of Robert Latimer and his severely physically and
mentally disabled daughter, Tracy Latimer. Robert killed his daughter by carbon monoxide
poisoning and argued he had done so to spare her from further suffering. He was convicted
of second degree murder in 1994 and spent 10 years in prison. This case differed from that
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of Sue Rodriguez in various ways, but one crucial difference is that another person had
made the decision to end the life of someone and without obtaining that person’s consent.
Opinions were divided across the country in both the Sue Rodriguez and the Robert
Latimer cases, but it is clear that even though the law has not been changed yet, the trend is
toward greater public acceptance of euthanasia. This is especially the case in Quebec where
opinion polls show greater than the Canadian average support for euthanasia. For example,
to the question, “Generally speaking, do you support or oppose legalizing euthanasia in
Canada?” 63% said “support” while 24% said “oppose”. In Quebec, 78% of respondents
chose “support” To the question “Do you agree or disagree with allowing a parent to
euthanize their child who suffers from a severe form of a condition, such as cerebral palsy?”
36% of Canadians said “Agree” while 46% said “Disagree”. In Quebec, however, 52%
chose “Agree” and 34% chose “Disagree” (Angus Reid Public Opinion, “Majority of
Canadians Support Legalizing Euthanasia”).
5. The Current Euthanasia Debate in Quebec
In Quebec, the issue of legalization of euthanasia has also occasionally made headline
news. In 2009 the federation of Quebec medical specialists made the front pages with the
publication of a poll that claimed that 75% of specialists “…were ‘certainly’ or ‘probably’
in support of legalizing euthanasia as long as the practice were strictly regulated” (“Quebec
specialists support legalizing euthanasia”). As mentioned, public opinion polls on
euthanasia and assisted suicide consistently show Quebeckers are more in favour than the
Canadian average. Some speculate that this may have to do with the rejection of religious
values during the Quiet revolution. As Quebec’s Dying with Dignity Report states:
In the past, society was more homogeneous and subject to various authorities.
Death had a different meaning then, mainly because of religious references. But
the expiatory suffering of yesteryear has lost its meaning, resulting in the
unwillingness to tolerate prolonged suffering. Personal autonomy, inviolability
and integrity, along with pluralistic values, have become the cornerstones of
[Quebec] society.
In 2010 a Bloc Quebecois MP, Francine Lalonde, proposed a bill to protect doctors who
help their terminally ill patients end their lives but it was defeated in Parliament. That same
year, the Quebec government began a “Dying with Dignity8” commission which toured
the province to gather information, arguments and to hear the opinions of Quebecers on the
issue. The Report it produced, recommended that patients be allowed to request their deaths
under certain clearly defined criteria and that doctors be allowed to provide it for them.
Recommendation 13 states the following:
The Committee recommends that relevant legislation be amended to recognize
medical aid in dying as appropriate end-of-life care if the request made by the
person meets the following criteria, as assessed by the physician:
o The person is a Québec resident according to the Health Insurance Act;
8
Although the Commission’s mandate was to provide a forum for all views on end of life issues, the phrase
“dying with dignity” is often connected to those who advocate legalization of euthanasia.
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o The person is an adult able to consent to treatment under the law;
o The person himself or herself requests medical aid in dying after making
a free and informed decision;
o The person is suffering from a serious, incurable disease;
o The person is in an advanced state of weakening capacities, with no
chance of improvement;
o The person has constant and unbearable physical or psychological
suffering that cannot be eased under conditions he or she deems
tolerable.
The legal changes required to implement these and other recommendations are under the
Criminal Code (namely, section 14 mentioned above in the Sue Rodriguez case) and thus
within the jurisdiction of the federal government rather than the provincial government.
However, responsibility for administering these provisions of the Criminal code still fall
into the hands of the province. The provincial government could thus choose not to
prosecute medical staff who provide assistance in dying to their patients and for all practical
purposes, permit the practice of active euthanasia in Quebec. The previous PQ government
of Pauline Marois had already expressed its intention of moving swiftly on this issue to
bring legislation facilitating euthanasia in certain cases but was disrupted by defeat in the
election of 2014. The new liberal government of Philippe Couillard moved quickly,
however, to pass the legislation. Bill 52 became Law 52 “An Act Respecting End of Life
Care” in June 2014.
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C. Issue #4: The Health Care Debate
1. Introduction
The decision to create public health insurance, like the Canadian Medicare system,
has had a profound impact on the lives of the average person and has allowed the benefits
of modern science and medicine to be shared by a greater percentage of the population. This
decision is due to a number of reasons but a key factor were concerted public campaigns and
political pressure over many years to improve the lives of the majority of the people. Thus
the health and well-being enjoyed by people in the developed world is not just a result of
science and technology but of political mobilization and organization which defenders of
public insurance view as a victory of the ethical principles of equality and social justice.
After all, even the best medical treatment will not help someone who cannot get it because
he or she cannot afford it. The crucial point here is that health care is not only a question of
what medical science and technology can deliver but about how effective the people are in
pushing the political system to provide access to those benefits.
Many believe the public health system is under attack in Canada and other
western countries. The United States, though the world leader in medical science, still has
no public health insurance system comparable to Canada’s or many other Western
countries. Most health care in the US is delivered through private, for profit medical
insurance, though important government run insurance programs do exist. According to the
US Census Bureau, in 2003, 43.6 million people had no health insurance coverage in the
United States (US Census Bureau). Faced with escalating health care costs, deficits and
economic recessions, governments have tried to cut back on the funding of the public
health care system. In Canada, Alberta’s Bill 11 sought to privatize some of the services
presently funded and available in the public system. Under this proposed law, in other
words, people will have the “option” to pay for certain health services or wait in line in the
public system. In Quebec, thousands of people still do not have a family doctor, a patient’s
main entry way into health care and waiting times remain a major problem. At the same
time, Quebec has witnessed a rapid growth of private, for profit clinics offering medical
services that bypass the long waiting lists many have to endure in the public system. Critics
have attacked this as establishing a “two-tier” system of health care – one presumably better
and faster system for those who can afford it, and another lower quality system for the rest
of the population. These critics fear that Canada will adopt a more American style of for
profit health care. Supporters or private health care, on the other hand, argue that a mix of
private and public health care would reduce pressure on the overburdened public system
and improve wait times.
Though the federal government has promised to prevent violations to the Canada
Health Act, the law that tries to ensure equal access to health services, it is evident that
more services are now privately available and the services offered in the public system are
often difficult to access in a timely way. The Federal government itself has seriously
reduced funding for health care in the past and present levels of Federal funding still do not
match those of the early 1980s. The provincial governments now find themselves footing a
greater percentage of the financing for health care while Quebec has embarked on a serious
austerity program which seeks to reduce the budget largely by cutting spending for social
programs like public health care.
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Meanwhile, under the leadership of President Obama, reformers in the US have
fought hard to establish greater accessibility to health care coverage for that country. Most
recently, the Affordable Care Act and the Patient Protection Act (aka “Obamacare”) has
been passed which seems to have improved accessibility somewhat, though millions remain
uninsured. But changes to the US public health system are as much an ideological
battlefield as are changes to the Canadian system. Billions of dollars are at stake and
Americans remain seriously divided over the issue. The American example of health care is
often used as a warning to Canadians about what privatization might mean but other
countries provide other models that are sometimes presented as providing another
alternative or solutions for Canadians. Often, however, these also involve allowing a greater
role for private, for profit medical services. The purpose of this section of the course is to
provide basic information enabling you to make a more informed decision on where you
stand on the issue of health care privatization and on what would be the most ethical
direction to take for the future of health care in our society.
2. The Health Care Debate in Canada: A Brief Summary
Most Canadians are deeply attached to our public health care system, also known as
Medicare9, and some even see it as part of what defines us as a people. All political parties
claim to want to defend the public health care system but that has not stopped funding cuts
that may be partly responsible for what some call a crisis in the system today. Steadily
increasing costs due, it is claimed, to the aging population, expensive new high tech
machinery and drugs, as well as other problems such as long waiting times has provoked a
search for a solution to the problems of Medicare today. One proposed solution is to restore
funding to levels that would ensure reasonable waiting times and enforce the rules
guaranteeing that every Canadian has access to quality health care. Others claim that more
money is not the solution. Some of these critics have argued that the government should
allow a greater role to private health care insurance and allow market competition to
encourage greater efficiency in health services. Few of these people say we should
eliminate government run health care entirely, but argue that a greater role for the private
sector and competition would provide more services and complement, not replace the
existing public system while lightening the tax burden. There are fears, however, that this
solution would spell the end of the public system in Canada and introduce a private,
American style profit orientated system instead. The following provides some historical
background to the present Canadian public health care system and examine some of the key
points in the debate on privatization of health care.
Background
The Canadian Health care system, also called Medicare, is a largely publicly funded
national system funded and administered by both federal and provincial governments.
“Publicly funded” means that it is funded by tax dollars Canadians pay to governments
rather than directly by patients to doctors or insurance companies. Its origin can be traced
back to the Great Depression of the 1930s when health care in Canada (and most
9
In the US, “Medicare” and “Medicaid” refers to a narrower set of government funded health insurance
programs that cover some older people, the disabled and others. Most people are not covered by such but
purchase health care through employers and private companies. Some are not covered by any health insurance.
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countries) was private and for profit. This means that people's ability to pay determined
whether or not they received professional health care. The impoverishment of a large
number of Canadians caused by the collapse of the world economy during the Depression
increased demands for government assistance in various areas, including medical care.
Some governments responded to this call, in the period during World War II (1939-45)
and especially after (1945-75).
Especially important was the Saskatchewan based Commonwealth Co-operative
Federation (CCF), a political party and social movement headed by Tommy Douglas
(1904-1986). The CCF was the first socialist government elected in North America when it
assumed power in the province in 1944. Douglas was strongly influenced by both socialist
and Christian ideas and believed the state should play a bigger role in guaranteeing people
certain basic needs, including health care. As premiere of the province Douglas
implemented a series of laws that established the first government- funded comprehensive
medical system in Canada, though not without considerable opposition.
Douglas left the provincial political scene in 1961 for Ottawa to lead the newly
founded the New Democratic Party (NDP) in the hopes that he would have equal success
on the national level. The NDP was in large part a creation of the CCF but revamped to run
on the national level and to appeal to a broader range of Canadians. It maintained some of
its socialist ideas and under Douglas's leadership campaigned for a national health
insurance program similar to Saskatchewan's.
Though the NDP never won a federal election, the idea of national health insurance
program caught on, helped by pressure from the NDP, the example of Saskatchewan and
public demand across the country. The post war period (after 1945) and especially the
1960s witnessed strong demands for the construction of a "welfare state" in many Western
countries. This included ideas about government funded and government run pension plans,
unemployment insurance, family allowance, welfare and health insurance. In 1966 the
federal government introduced "Medicare" across the country, making itself responsible for
50% of the funding. The other 50% was to be the provincial governments' responsibility.
The Canada Health Act
By the mid 1970s, the pressure for government funded solutions to social problems like
health care and poverty began to decline. Faced with an economic recession and significant
budget deficits, governments began to cut back on the "welfare state" in general, including
health care funding. In 1977 the Trudeau government replaced the 50-50 funding formula
with "block" grants to the provinces, in effect lowering the federal government's
contribution. Despite this, pressure for more comprehensive national health insurance
remained and in 1984, the Canada Health Act was passed and became the key federal law
establishing our modern day health insurance program. The Act banned "extra billing" by
doctors and established a number of key principles that were supposed to guarantee access
to medical care for all who needed it across the country. These key principles included the
following:
Public Administration: All administration of provincial health insurance must be
carried out by a public authority on a non-profit basis. They also must be
accountable to the province or territory, and their records and accounts are subject
to audits.
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Comprehensiveness: All necessary health services, including hospitals,
physicians and surgical dentists, must be insured.
Universality: All insured residents are entitled to the same level of health
care
Portability: A resident that moves to a different province or territory is still
entitled to coverage from their home province during a minimum
waiting period. This also applies to residents which leave the country.
Accessibility: All insured persons have reasonable access to health care
facilities.
In addition, all physicians, hospitals, etc, must be provided reasonable
compensation for the services they provide (Canada Health Act).
Money, Money, Money
The Act seems to spell out a fairly complete plan for coverage of every Canadian
citizen regardless of the ability to pay but the issue of funding and enforceability of these
principles has always been a major concern and especially so in recent years. Obviously,
without sufficient funds many of the principles mentioned above could be compromised.
Already the Trudeau government had reduced the share of funding from the federal
government. In 1995, again as part of an overall strategy to reduce the federal deficit,
Paul Martin's government introduced the Canada Health and Social Transfer (CHST)
which further reduced the federal government's share of health care funding. The provinces
would have to pay more for health care than before or would have to reduce services. In
2004, under the Martin government, a 10 year Health Accord was signed between Ottawa
and the provinces, providing a 6% increase in federal money for health care. The agreement
ran out in 2014. Prime Minster Stephen Harper has declined to renew the agreement or
even engage in renewed talks with the provinces on new funding. Instead, the federal
government has committed itself to continuation of a 6% increase until 2017-2018 but
thereafter, increases to health care spending will be pegged to growth in the economy
(relative to GDP). Critics contend this is really another cut in spending, further reducing the
federal government’s share of spending from the current 20% toward an estimated average
of 12% in the long run.
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According to the Canadian Health Coalition,
…the current federal government is transferring up to $36 billion less than they
would under the formula in the previous accord. It will contribute an historic low of
the total costs of Medicare – under 12% from the current 20%. This unilateral
change in the funding formula hits poorer provinces hardest. Furthermore, tying
increases to economic growth means that in hard times, when health needs increase
and provincial capacity to meet those needs is weakest, the federal government
contribution will decline. Taken together this is a formula for fragmentation,
inequity, and a race to the bottom. (Canadian Health Coalition)
Presumably, the gap in funding will have to be made up by the provinces by cuts to
provincial health care programs or through increased taxes or increased privatization of a
combination of all three. Many Canadian supporters of public health see this history of
declining federal funding, as well as an inability or unwillingness to produce a greater
number of health care workers, as a major cause of problems in today's Medicare system,
including the long waiting times for important medical services.
On the other hand, others argue that more money is not the solution. They warn
about excessive and “unsustainable” government spending while claiming that more money
will not solve these chronic problems. They argue that the privatization of some medical
services provides a better solution allowing for improved services without raising
government expenditures and the tax burden. Beginning in the 1990s and continuing to this
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day, various provincial governments began to introduce private, for profit health care
services. In Alberta, the provincial Conservative Party, headed by Ralph Klein began to
allow private hospitals. In this case, the motive for introducing privatized services stems
from a conservative viewpoint that criticizes government run services and many "welfare
state" measures as inefficient and costly and claims a private for profit "free market" system
would be cheaper, more efficient, reduce waiting times as well as overcrowding in
emergency rooms.
Quebec, under the Charest government also has allowed the growth of private
clinics that charge patients for surgery and other services – a practice which would seem
to violate the Canada Health Act's principle of accessibility. One reporter says that
"Montreal has become the private health-care capital of Canada, offering a wide range of
medical services to those willing to pay out of pocket to bypass the public system"
(Derfel).
The Chaoulli Case
Another possible threat to the Medicare system has come from the 2005 Supreme
Court ruling in Quebec called "The Chaoulli case," named after Dr. Jacques Chaoulli, who
argued on behalf of his patient George Zeliotis. Dr Chaoulli argued that his patient's life and
security were being put in danger because of the excessive waiting time for his medical
treatment. Private services could not be used by his patient because of the province's legal
ban against private clinics charging for services already offered by the public Medicare
plan. Dr. Chaoulli argued that banning private services violated key parts of his patient's
rights to "life and security of the person" as spelled out in both the Quebec Charter of
Rights and in the Canadian Charter of Rights and Freedoms. The purpose of the Quebec
law banning private services when public ones are available stems from the view that
allowing private services would create a "two-tiered" system whereby those with money
could get quick and timely health services while those without would have to wait.
Moreover, as was argued during the trial and elsewhere, the existence of private services in
such cases would actually undermine the public services since the limited pool of doctors,
nurses and other health-care resources would be drawn to the more lucrative private sector
leaving the public system even more starved than at present.
The Supreme Court judgment was close, with a ruling of 4 to 3 in favour of
Chaoulli and against the Quebec law. The judges in the majority decision agreed that
excessive waits were a threat to the life and security of the person and that the banning of
private services was thus a violation of the Charter and unconstitutional or illegal. The
Quebec government was directed to lift its ban on private services but the judges agreed to
an 18 month delay so the government could prepare to implement the directive.
The decision in the Chaoulli case raised fears that sections of the Canada Health Act
guaranteeing access to health care based on need rather than ability to pay would have to
be struck down because of the ruling that long wait times violated the Charter. Concerns
were expressed that laws in other provinces like Quebec's limiting or banning private
services would also now be ruled unconstitutional. Some interpreted this as meaning that
there would now have to be a private "parallel system" of health care alongside the public
one. But as former Liberal federal health minister Ujjal Dossanjh said at a meeting in
2005, "[The Chaoulli case] did not, as some have suggested, rule that the Charter of Rights
and Freedoms requires the creation of a parallel private system". Instead he said the ruling
states that when the public system provides a vital health service, governments are obliged
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"to ensure that medically necessary care is provided within a reasonable time (quoted in
Canadian Medical Association's Annual General Meeting. “Speaking Notes for the
Honourable Ujjal Dosanjh”).
In 2006 Bill 33 was passed, confirming the legality of privately owned clinics and
making them, in effect, a destination for some of those not able to receive timely enough
services in the public system.
The Bill will give doctors permission to run publicly funded, privately owned, forprofit surgical centres. It will also create a wait list management system in public
hospitals to determine when overflow patients must be sent to private clinics. And it
will end the province's absolute ban on private medical insurance, which will now be
available — albeit only for hip, knee and cataract procedures (the operations with the
longest wait times) in private clinics. (Solomon)
Today it appears that private clinics and medical services have proliferated in
Quebec and in other parts of Canada (Glauser). The debate rages on as to what impact this
will on the pocket books of Canadians, on the efficient delivery of health care services and
on the health of Medicare itself. Meanwhile, the Couillard government in Quebec, under
the guidance of health minister Gaétan Barette has embarked on a pledge to reduce the
provincial deficit, including through important cuts to health care spending via proposed
legislation (Bill 10 and Bill 20).
Public or Private?
Waiting times are a crucial issue in health care delivery in Canada and governments
have at times made moves to address the issue. In 2005 more money was injected into the
system by the federal government and in many cases the number of operations per year
increased dramatically. For example knee surgery operations have increased by 77% in
2002-3 compared to 1994. Hip surgeries increased by 33% in the same time period
(Canadian Institute for Health Information. Funding, however, is still not at the level it was
before the cuts made by Prime Minister Paul Martin in the 1990s and long wait times for
many medically necessary procedures remain. More recently, the Harper government has
continued the long term decline of federal government contribution to health care funding.
While the federal government has pledged a 6% increase to health care spending up to
2017, thereafter, spending will be tied to economic growth, including inflation. According
to the Toronto Star:
Currently, federal health transfers make up about 20 per cent of provincial health
spending, a share that is expected to drop to 18.6 per cent between now and 2036 if
the government keeps transfers to around 4 per cent annually. (Wallace)
This is a far cry from the “50-50” split between federal and provincial governments that
once existed. The provinces will have to make up for the shortfall somehow by increasing
taxes, cutting services or increasing privatisation.
Supporters of public health care are often deeply suspicious of the real commitment
of the Liberal and Conservative parties, whether federal or provincial, to the Canadian
health care system. Some even claim that these governments have purposefully
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underfunded the system so that people would then be prepared to accept increased
privatization. They see the deterioration of health care services in the context of the
attack on welfare state policies begun in the mid 1970s. They point to the influence of
conservative US economic, political and social policies as a major factor in pushing or
supporting Canadian governments in eroding the present health care system. Especially
important, they claim, is the influence of American private health insurance and
pharmaceutical companies who would love to expand into the Canadian market. Sometimes
fears are voiced that the North American Free Trade Agreement (NAFTA)
will allow private US based companies to establish their presence in Canada and, again,
undermine the public system. At the same time, the deterioration or elimination of the
Canadian public system would help to silence calls for a public health care system in the
US.
Proponents of privatization, on the other hand, accuse supporters of Medicare of fear
mongering and hysteria. Most proponents reject the accusation that they are trying to
destroy the public system and state that they simply want to allow private health care
providers to supplement and work alongside the public system, not to replace or undermine
it. They are skeptical that increasing funding will help things since governments are
notoriously inefficient, they claim, compared to private enterprise. Furthermore, funding
may be insufficient to meet astronomically rising costs due to the aging of the population
and expensive new drugs and machinery. They note how the US leads the world in medical
research and innovation, has much more high tech equipment per capita as well as shorter
waiting times than in Canada. Privatization, they say, would provide these benefits in
Canada, too, while reducing government expenditures and providing more choice.
3. Health Coverage and Access in the USA
One way to envision the possible effects of privatization is to look at the US where
private, for profit companies, called health management organizations (HMOs), provide
health insurance for much of the population. Insurance is most often obtained through
employer group insurance plans funded by employers, workers and both state and federal
governments. Those without employment can apply for individual coverage, also provided
by private health insurance companies. The US federal government has also instituted
various programs, such as Medicaid and Medicare that provide health insurance to lower
income Americans. Medicaid covers over 50 million Americans, including seniors, those
with disabilities and others who might not otherwise be
Covered (“Quick Facts About Disparities”). Medicare in the USA, not to be confused with
the Canadian Medicare system, also offers coverage to lower income Americans, especially
to seniors aged 65 and older and to the disabled. Coverage can vary widely depending on
what type of health plan an employer gets for his employees, what state one lives in,
whether one is on Medicaid, Medicare and other factors.
Despite these federal and state sponsored programs, in 2002, about 43 million
people in the USA had no medical health insurance coverage (US Census Bureau), the
majority of them from lower income groups and racial minorities. Others were
"underinsured", meaning that their level of insurance was insufficient to meet potentially
costly medical treatments. Supporters of the Canadian system point to these supposed
inequalities and inefficiencies of the American system that leave so many people uninsured
and underinsured.
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Moreover, recent statistics indicate that even those who may be better off face
serious financial problems related to health expenses since these account for half of the
personal bankruptcies in the country. They point out that private health insurers are
motivated to insure only those who are young and healthy and often refuse coverage to high
risk people and those with "pre-existing conditions". Many authors note the marked
differences in the quality of health care offered to the wealthy with that provided to the poor
and various minorities (American Nursing Association). They note, as well, that the
American system, while offering only incomplete coverage of the population was actually
far more expensive than the Canadian system or, indeed, any other public system in the
developed countries. This is especially the case when examining the administration costs of
each system. According to recent research, the US spent about $294.3 billion on health care
administration, amounting to about $1059 per capita, while Canada spend only $307 per
capita (Woolhander 21).
Expenditures on administration in the US was 31.0 per cent of health expenditures
while it was only 16.7 per cent for Canada. American doctors themselves sometimes
express frustration at the cost and amount of “paper work” involved in their practices.
Patients, their families, and physicians must complete a multitude of forms, often for
several carriers, involving significant time and expense. Patients and their families are
burdened with paperwork when they are most vulnerable – worried and sick.
Physicians must also respond to demands for documentation and justification from
insurance carriers and quality review organizations. These frustrating layers of review,
which involve demands to justify clinical decisions, requirements for prior approval, and
denials of payment, undercut provision of high quality care for all patients by
inappropriately second-guessing professional judgments and intruding into physicianpatient relationships (American College of Physicians 124-131).
“Obamacare”
The election of President Barack Obama in 2009, raised new hopes that the
American health care system could be reformed to increase coverage and eliminate some of
the worst disparities. After a very emotional battle during his first term, the Obama
government was able to pass a compromise version of health care reform with a series of
bills including the Patient Protection and Affordable Care Act that expanded Medicaid
coverage, banned denial of claims or coverage based on “pre-existing conditions” and
provided support for small companies to fund their employees’ health insurance (“Patient
Protection and Affordable Care Act”). Although there is still no universal coverage, the
health reform did expand coverage to a larger section of the population and represented an
important victory to health care reformers given the history of past failed attempts in the
USA. At the same time, the Obama health reforms promise to actually save the federal
government money in the long term, reducing “federal deficits by $210 billion over the
2012–2021 period” (US Congressional Budget Office (CBO). This is an important
consideration since rising health care costs, whether in the US or Canada is one important
cause of all government expenditures. However, the reforms maintained and even
strengthened the private insurance providers and market driven, for profit system of US
health care. This is because more individuals and businesses will be forced to register with
these companies or pay a fine. Moreover, pharmaceuticals companies will continue to
charge the highest rates in the world for their drugs.
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4. Conclusion and Ethical Reflection
Whether the motivation is to save money or to increase coverage and delivery, the
future of accessible health care remains an open question in Canada, the USA and in
other wealthy countries. Will America eventually succeed in achieving a universal health
care program, as all other western countries have done? Will the federal government’s role
in delivering health care grow there? Will Canada continue going down the road of
increasing privatisation and, if so, does that mean that we will have eroded the promise of
health care to all citizens regardless of ability to pay? The future is unknown but much
depends on how attentive average citizens like you are to the debates and facts surrounding
health care. Much depends, as well, on the ethical principles we choose to apply to the issue
of health care. Do we still favour an ethics of equality and justice or do we favour that of
autonomy and individual choice? What is the most ethical road to follow according to you?
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D. Issue #5: Genetic Technology
Genetic engineering (also called recombinant DNA science and technology, gene
splicing, etc…) might well be one of the greatest and perhaps most dangerous of scientific
and technological advances of the 20th century. It continues to have an enormous impact on
everything from the food we eat to our environment, medicine, pharmaceuticals,
criminology, and even our ideas about human nature. For this reason, some writers call the
development of genetic engineering and all the consequences that flow from it, the
biological revolution or the genetic revolution, a revolution in our understanding of and
in our ability to manipulate the genetic basis of life. As this implies, the biological
revolution proceeded in two phases here, first in our understanding of genes and then in our
ability to control and manipulate them. As in other fields of science greater understanding
often leads to greater control and proves
once again, that knowledge is power.
In the following sections we focus first on the scientific developments that
contributed to our greater understanding of genes, beginning with the discovery of the
structure and function of the DNA molecule and continuing on with our increased ability to
“read” and decipher how different stretches of DNA are responsible for different traits and
characteristics in organisms, whether bacteria, plants, or animals including humans (gene
expression). Next we try to show how scientists began to use this greater understanding of
DNA and other aspects of the microscopic world of life to actually alter, manipulate and
control genes (genetic engineering).
1. Background: Discovering the Structure and Function of DNA (1940-53)
The story begins with Gregor Mendel’s discovery of the mechanisms of heredity in
the 19 century. Mendel’s work indicated that there were particles or “units” of heredity,
responsible for the traits of organisms. Since then, the hunt has been on to discover what
these basic “units” of heredity (the genes) are. In 1952 experiments involving virus and
bacteria, confirmed that it was DNA - deoxyrobonucleic acid – a complex molecule within
the chromosomes of cells that carried genetic information directing cells to specialize and
form the various parts of a working body. In 1953 James Watson (1928- ) and Francis
Crick (1916- 2004) succeeded in establishing a model of the structure of DNA which
showed how it could both express and accurately transmit genetic information10. They
showed that the structure of DNA – its shape and composition – makes it the command
center that tells the cell what kind of cell it will be (skin, lung, blood, etc…) and also
explains how it regulates the growth, life support system, and reproduction of cells. Once
they published this model in 1953, it became clear that Watson and Crick had indeed found
the so-called “blueprint of life” since all living things have DNA (or its close relative
th
10
Credit should also be given to Rosalind Franklin (1920-1958) who pioneered the technique of X-Ray
crystallography that showed the structure of the DNA molecule. Unfortunately, Franklin died and was
therefore not awarded the Nobel prize along with Watson, Crick and Maurice Wilkins when they received it in
1962.
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RNA). And it is this molecule that “gives the instructions” to make, grow and maintain the
various kinds of cells that make up a living being.
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Their Nobel Prize winning model
proposed that DNA was a molecule
composed of two main strands, twisted
together into a double helix structure,
like a twisted staircase joined by the
steps or the “ribs” of the molecule. The
“backbone” of this staircase was
composed of sugar-phosphate while
the “ribs” (the joined steps) are called
nucleotide bases that come in four
“flavours”: Adenine (A), Thymine (T),
Guanine (G) and Cytosine (C). These
bases glue the two strands of the
molecule together. The order of these
bases along a stretch of one strand of the
DNA molecule, for example, “ACTG”
as in the illustration on the left, is called
the sequence of base pairs. Note that
the sequence along one of the strands
can tell us what the sequence on the
other strand will be since “A” can only
pair up with “T,” and “C” only with
“G”. Thus for the left handed sequence “ACTG” we would have a complementary right
handed strand of “TGAC”. The double stranded shape of the DNA molecule explained how
genetic information could be replicated (copied). If DNA was “unzipped” into two strands,
each strand contained the necessary information to produce a complementary (“mirror
image”) strand from the free floating base pairs in the cell. Thus one strand of the molecule
acted as a template (like a mold) for the other. Since replication (reproduction) of cells is a
fundamental process in all living things, this confirmed that DNA must be the basis of
heredity.
The shape and structure of Watson and Crick’s DNA also eventually provided part
of the explanation for gene expression: how genes provide the information to make and
maintain the various kinds of specialized cells and cell parts that make up the tissues,
organs, etc… of a working body. The sequence of nucleotide bases of the DNA molecule
are what ultimately “spell out,” in a complex multi-step process, the instructions to make
cells and most of their vital parts. The entire process can be further clarified by a frequently
made analogy to letters, words and sentences in a language. The nucleotide sequences of the
DNA molecule are analogous to a 4 letter “alphabet” (ACTG) which, in varying length and
order, can “spell out” certain “words” (amino acids) which eventually combine into
“sentences” (proteins) responsible for the structure and function of various cells. Since
cells make up most of our bodies, we understand how DNA is the blueprint
of life.
Given the complexity of the process, conducted millions of times a second
throughout the whole body of an organism (as well as in the developing embryo), it is
remarkable how accurate DNA replication and protein synthesis (creation of proteins)
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normally are. However, certain errors or mutations in copying or synthesis sometimes
occur. If these errors happen in an important part of the genetic code, a hereditary disease
may result. Some hereditary diseases, such as sickle cell anemia which affects some east
Africans or their descendants in America and elsewhere are the result of a single “mistake”
in the sequence of DNA coding for hemoglobin - a key protein in blood cells. Other
hereditary diseases have more complex causes, occurring at other stages in protein synthesis
or may be a result of chromosomal or other anomalies. Moreover, various
mutagenic agents have been discovered in the 20th century, responsible for rearranging,
deleting and adding to normal sequences. From the evolutionary perspective most
mutations are harmful, if not lethal to an organism. Thus the discovery of DNA also helped
clarify the root causes of certain genetic diseases.
A much clearer idea of what genes were emerged from all this work. Genes were
redefined as stretches of DNA of variable length containing various sequences of
nucleotide bases that ultimately “code for” or produce essential proteins, key components of
all living beings. The genetic source of all of these was the DNA molecule as revealed by
Watson and Crick.
2. Gene Mapping and Sequencing (1976-1999)
Now that geneticist had a much clearer understanding of what genes were and how
DNA functioned, progress in actually understanding what parts of the genetic code were
responsible for specific traits and characteristics proceeded rapidly. This is what we refer to
as “reading,” deciphering or mapping and sequencing the genetic code. It
involves locating what DNA sequences within a specific chromosome are responsible for a
specific trait or characteristic. At first, attention was focused on finding gene sequences that
were responsible for hereditary diseases. The job was difficult since the human genetic code
is about 3 billion base pairs long but in the 60s and 70s various teams of scientists still
managed to locate genes responsible for diseases like cystic fibrosis, multiple sclerosis,
sickle cell anemia and others. This means they could isolate the sequences of DNA in a
specific region of a specific chromosome responsible for the disease.
By the 1990s, however, the US government, along with other governments in the
developed world and research institutions began a much more systematic and large scale
project to map and sequence the entire human genetic code (called the human genome). In
1990 this job was given to the US National Institutes of Health and the Department of
Energy and called the Human Genome Project. They were given 15 years to do the job of
locating not just disease genes but all genes in the human body.
Much of the laboratory work in sequencing and mapping DNA sequences is
repetitious and mechanical. But computers took over some of these tasks, increasing both
the speed and accuracy of the job. Scientists thus built a sequence map of the human (and
other animal) genome, detailing the chemical structure of the genetic code at the most
fundamental level and showing what proteins it “codes” for. Today this technique has been
refined and partly automated; allowing the deciphering of thousands of base pair sequences
in a fraction of the time it took just ten years ago. With this information, the
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entire human genetic code (the genome) and, eventually, knowledge of what each part of
that code does in building or maintaining a human body, is now revealed.
Walter Gilbert, a pioneer in the field, calls gene mapping and sequencing “the holy
grail” of biology. This is because such detailed maps provide the information detailing
exactly what genes are doing what in the human body. Possessing such information we can
discover what genes are responsible for triggering various kinds of hereditary diseases,
certain types of cancer and other diseases that have a genetic or partly genetic component.
Once known, genetic tests can be created that will be able to spot whether someone has or
does not have the “faulty” sequence. Moreover, this can be done before birth as has been
the case for Down’s syndrome for many years and for literally hundreds of genetic diseases
or weaknesses today.
Beyond diseases, we can discover the source of many “normal” genetic or party
genetic traits. Perhaps we will discover genes for homosexuality, or intelligence, or
creativity or other behaviours and traits, as some already claim to have done11. Genemapping promises to reveal, according to some of its proponents, the very roots of human
nature. To enthusiasts of gene-mapping the possibilities are endless. But we need to be
careful of such claims. If you already believe that human nature is primarily a question of
genes, then gene-mapping may indeed be the “holy grail” for you. Exactly how useful
and important gene-mapping will be, especially on the question of human nature, should not
be pre-judged. So far, it has produced nothing like a major breakthrough linking mental
traits to genes. But the potential is still there and many other benefits - and
dangers - have already emerged from genetic engineering in general and gene mapping in
particular.
3. Bacteria and Viruses as Genetic Engineering Tools
Knowledge of the exact chemical structure, function and location of genes were
crucial first steps toward their eventual control and manipulation, i.e., towards genetic
engineering. Though microscopically small, not only were microbiologists eventually able
to find tools for “reading” DNA, they also succeeded in developing powerful new ways to
actually “write” and “edit” or manipulate the genetic code of organisms in ways never
before imagined. This was due largely to the work done with bacteria and viruses in the
field of molecular biology. The development and expansion of this new found ability to
understand, manipulate and “engineer” the genetic code is at the heart of the biological
revolution; a revolution that has continued, expanded and intensified to the present day.
As powerful as the modern microscope can be, it cannot cut, delete, glue or alter
stretches of DNA or genes. No “scalpel” or other conventional tool delicate or tiny enough
to do this job by comparatively gigantic and awkward human hands can do this job in this
microscopic world. Nature, however, already conveniently provides such microscopic
“tools” which have been doing exactly this for billions of years. Molecular biologists lost
no time in harnessing these tiny “genetic engineers” for their own purposes. These are the
11
Dean Hamer is one scientist who claimed to have discovered a “gay gene”. Other claims about genes for
equally controversial behavioural characteristics keep forthcoming from scientists. Obviously, these need to be
critically and carefully scrutinized and verified, given what this book has shown about the misuse of biological
knowledge. Hamer’s own work has been severely criticized as scientifically inadequate.
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viruses and bacteria cell biology had already discovered long Before DNA. Researchers
chose to study bacteria and viruses because they were the simplest living things and because
they reproduced very quickly. Their importance in spreading infectious diseases was known
since Louis Pasteur in the 19th century, as were their more beneficial effects in various
quarters. Bacteria are one-celled organisms that have no nucleus but do have genetic
material, whereas viruses don’t even have cells and were once thought to have no genetic
material 12 but this is not the case. A virus is little more than a protein coat containing a
string of DNA. A favourite bacterium of geneticists has been Eschericia coli (E. coli), that
exists in the human intestines and a favourite set of viruses has been the bacteriophage that
attacks E. coli. Unlike bacteria, viruses cannot reproduce by themselves but need to
“hijack” a cell and use its machinery to duplicate themselves (replicate). A virus can infect
people, for example, when it latches on to a cell wall and injects its genes through the wall.
The virus genes then insert themselves into the genetic code of the cell they have invaded
and use the genetic machinery of the cell to duplicate themselves and their protein covering.
If successful, viruses multiply so fast in the host cell that they burst right out of the cell,
destroying it and releasing other copies into the cell’s environment to continue the cycle
and cause the disease symptoms.
However, a virus’s ability to insert its own genetic material into the genetic code of
a cell provided scientists with a valuable tool for inserting the genes of one organism into
those of another. If they could substitute the virus’s genes for other, more useful genes, they
would have a means to insert useful genes into a cell and thereby modify what the cell was
doing. In other words, bacteria and viruses could be used as delivery systems or vectors to
insert genes into a cell. This is exactly what scientists have been able to do and today all the
tools are available for copying or cloning genes, for cutting them in specific places using
enzymes and for changing or inserting gene sequences using bacteria and viruses in any
number of ways. Thus it is that genetic science and technology have succeeded in
developing the techniques for reading, cutting, altering, adding and recombining various
stretches of DNA from any organism and this is what genetic engineering is all about. The
possibilities of genetic engineering are truly staggering and the sections above will give just
a small sample of what these are.
4. Some Current Applications of Recombinant DNA Science and Technology
Gene mapping and sequencing is perhaps the key to the continuance of the biological
revolution and is therefore one of the most important applications of recombinant DNA
science. This is because almost any present or future application of Recombinant DNA
science will require knowledge of DNA sequences. In this sense, genomic sequencing can
be (and has been) compared to the construction of a reference library or gigantic dictionary
of the “code of life” that others will use in any number of ways. Gilbert and others compare
it to an “infrastructure”13 necessary for the future advance of biology and medicine. Itself
the product of biological science and technology, it is of obvious value to continuing
12
Some have debated whether viruses are “living” at all since they lack even the most basic features normally
thought necessary to living things - such as the ability to reproduce. Many researchers conceive of viruses as
on the borderline between the living and non-living.
13
The word “infrastructure” is usually used to describe the network of roads, highways, bridges, the sanitation,
sewage, water and electrical systems upon which a modern economy depends to maintain itself. A welldeveloped infrastructure, in this economic sense, is also the pre-requisite of any economic growth in a modern
society.
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biological research and researchers who need to know the sequences of the genes they are
investigating in the lab. But the uses to which this knowledge can be put are numerous
indeed, like the uses to which the words in a dictionary can be put. The frequently used
metaphors of “dictionary”, “reference library,” “code” or “map” when referring to the
genetic “code” conveys the idea of a hidden language brought to light by modern science.
The metaphor of “map” seems to be particularly appropriate. Like Columbus, we have
discovered a new world and produced a new and more accurate map of its terrain. Like
Columbus we are about to change history forever. How will we treat this new world? Will
we plunder it for profit like conquistadors, driven by gold? Will we conquer it in the name
of the new god of science and technology and ravage, dispossess and colonize the new
lands we’ve discovered? Or will we have learned from the past and treat the new
knowledge we’ve gained with respect and humility? The answers are taking shape at the
moment but it is clear that much depends on how much knowledge “ordinary people” have
of current scientific developments and of the past uses and misuses of science and
technology. Without debate and involvement by the public, no hard questions will be asked
and we may simply be subjected to what others – “the experts” say.
The practical applications of modern genetic technology are too numerous to
mention here, but a small list may give an idea of why this is indeed revolution.
1. DNA fingerprinting and criminal forensics.
Variants of DNA sequencing techniques have been used in paternity cases, to determine
(or at least rule out) the genetic relation between a child and a parent. The O.J. Simpson
trial, not to mention shows like CSI gave wide publicity to the now widely used and
accepted technique of identifying an alleged perpetrator of a crime by matching certain of
his or her DNA sequences to blood, semen, tissue or other organic products found on the
crime scene. It is now also being used to discover the identities of the victims of war
crimes and their perpetrators, for example in Kosovo and Yugoslavia. This technology,
however, is becoming increasingly important in influencing decisions in criminal cases,
upon which proper justice and a person’s freedom or life will sometimes depend. The
prospect of a universal identification system, using DNA fingerprinting techniques, has
led some writers to contemplate a “Big Brother” scenario in which powerful interests will
have inside information on all individuals and their supposedly inherited mental and
physical weaknesses and strengths.
2. Pharmaceutical industry.
Knowing the sequence of a gene and its protein products can also be used to develop
drugs to counteract a genetic deficiency. Drugs like erythropoeitin (EPO) that stimulates
production of red blood cells and granulocyte-colony stimulating factor (G-CSF) that
stimulates the production of red blood cells, proven useful in the fight against anemia and
cancer, are only two examples of the potential medical benefits genetic sequencing
knowledge can have14.
3. Biotechnology industry.
Recombinant DNA techniques, combined with sequence data for micro-organisms,
14
Leroy Hood, “Biology and Medicine in the Twenty-First Century”, in Hood & Kevles, The Code of Codes,
op.cit., p. 159
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plants and animals, have allowed researchers to produce genetically altered strains of
important food crops that are more resistant to disease or that produce greater yields. In
fact, any number of desired traits can now be engineered into a growing list of living
things15. Such manipulation of living beings has raised opposition from animal rights and
environmental groups. The former argues that this represents another violation to the
rights of animals and the latter claiming that releasing genetically modified organisms
(GMOs) into the environment may have untold and uncontrollable consequences. Other
critics oppose the altering of food crops (GMFs) as potentially damaging to human health
and are especially critical of the lack of research in this area and the absence of warning
labels telling people which fruits and vegetables have been genetically modified. Another
key controversy surrounds the patenting of GMOs or DNA sequences. The ownership of
the genetic code of any living thing is seen as inherently abhorrent by some, with
especially serious consequences to independent farmers both here and in underdeveloped
countries. Critics paint a picture of how genetically modified seeds for crops will be
owned by large corporations, forcing everyone to buy or even rent something previously
thought a free “gift” of nature16.
4. Medical diagnosis, prenatal testing and genetic screening, another important
practical application of gene mapping and DNA science, is currently one of the fastest
growing fields of medical technology in the US. It is not hard to understand why.
Commercially, hundreds of millions of dollars can be made by developing tests for
various kinds of genetic or partly genetic diseases. But non-commercial considerations
are also important, with a host of politicians, activists and disability groups pressing for
research into the precise genetic causes of diseases like Huntington’s, cystic fibrosis,
sickle cell anemia and others. Pressure for more widespread testing by employers and
insurance providers is now growing in the US. Employers are looking for ways to cut
labour costs due to missed sick days and are especially anxious to avoid the high health
insurance costs associated with chronic illnesses17. Some private insurers themselves are
also pressing for access to the results of genetic tests among their clients. They fear the
consequences of “adverse selection” (“Whose Right to Genetic Knowledge?”) as more
and more individuals get tested for a host of diseases.
5. Gene therapy.
Gene therapy is “the insertion into an organism of a normal gene which then corrects a
genetic defect” (Anderson 401). While genetic screening allows us to search and find
“faulty genes”, genetic therapy allows us to replace these with “good genes”. The
alleviation of suffering and pain due to “genetic disease” is thus another tantalizing and
dramatic benefit that could emerge from Recombinant DNA science and technology. But
those afflicted with the most destructive and obvious “genetic diseases” (a relatively
small fraction of the population) are not the only potential beneficiaries of gene therapy.
15
cf. J.H. Barton, “Patenting Life”, Scientific American, March, 1991, pp.18-24 for some of technical, ethical
and economic issues emerging from this application of genetic engineering.
16
For critical perspectives on this issue see authors Jeremy Rifkin and Andrew Kimbrell of the Foundation for
Economic Trends.
17
In the U.S., medical insurance is largely supplied by employers through private rather than public health
plans (as is the case in Canada). This means that health insurance costs can weigh heavily on particular
companies, especially in the context of an aging population. Thus there may be some pressure to “remain
competitive” by finding a way to “screen out” individuals who reveal a genetic disease or even simply a
“pre-disposition” to certain diseases (cf. “Whose right to genetic knowledge”, Nature, vol. 379, 1 February,
1996, pp. 379-392).
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In the future, gene therapy may be useful to those who are “at risk” or have “genetic
vulnerabilities” or “predispositions” to a much wider range of diseases, including cancer,
heart disease and AIDS. This means, just about everybody since, as Francis S. Collins,
the director of the NIH’s Human Genome Project says “...we’re all at risk for something”
(Beardsley 102). But the same techniques used for treating genetic illnesses or
“predispositions” could also be used for “cosmetic” purposes or to enhance your baby’s
IQ (assuming, of course, IQ is genetic or partly genetic). The possibility of a new, more
technologically sophisticated eugenics, once again rears its head.
6. Cloning. A clone is an artificially created genetic duplicate of an organism. Cloning
of animals was made famous by Dolly the sheep but cloning of smaller creatures, microorganisms and segments of DNA has been going on for some time. Most controversial is
the idea of cloning a human being. However, much confusion reigns about this,
especially since Hollywood films began to make this a major theme in various sciencefiction movies. Cloning is often mistaken as genetic engineering of people, or “custommade” babies but this is different than creating a genetic duplicate and may in fact be a
greater ethical danger today. As mentioned, a human clone would probably be less
similar to the “original” than many people believe, unless one is predisposed to accept the
assumption that all we are is our genetics. Thus the idea of achieving immortality via a
clone or of “cloning Hitlers” is simply wrong. Though people often imagine scientists
making villainous zombie-like armies of clones, logically speaking there is no reason to
believe that a clone would be somehow more prone to control and manipulation than
anyone else, unless society decided otherwise (i.e., through discrimination). Ethically
speaking, there would be no reason to treat a clone as any less or more human than
anyone else.
Most scientists are more intrigued by the possibility of cloning human tissues and
organs rather than cloning an entire human. These could be used in transplants and to
repair damaged organs while eliminating or reducing the problem of rejection. If
successful, those would indeed be a major medical breakthrough. More recently the
possibility of cloning stem cells from embryonic tissue has become another practice
that has provoked controversy. Stem cells are unspecialized cells that can be injected into
damaged organs and tissues where they would presumably act to help repair and even
reverse the damage. The controversy lies in using parts of human beings (embryos and
fetuses) as medical products.
7. Evolutionary history.
Finally, genomic sequencing promises to yield dramatic new insights into our
evolutionary history. Already it is widely known that 98% of the human genome is
practically identical to the genome of the chimpanzee. More detailed contrasts and
comparisons between humans and other species on the genetic level may reveal
unsuspected relationships, connections and differences in the vast evolutionary tree of
life.
8. Discovering the “roots” of human nature? As important for the future as any of the
above-mentioned applications of genetic knowledge are, the discovery of genes or
complexes of genes regulating human emotional, intellectual and creative abilities,
promises to be even more revolutionary. The consequences of such findings would have
major implications on all of the social sciences and are already deeply affecting
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traditional views of human nature. Though little new solid evidence has emerged linking
complex mental traits to genes, the impressive growth of genetic technology in general
has encouraged a tendency to see a wide range of human traits and behaviours as
biologically and genetically based. Thus we witness alleged discoveries of “genes for”
obesity, alcoholism, sexual orientation, even political ideology, in television programs,
newspapers, magazines, radio and in lectures and conferences daily. If such “human
nature” genes could be found, we would indeed have discovered a powerful new way to
understand people and perhaps also to control them, whether for good or bad.
Establishing the validity of these claims requires that we look more deeply into the
scientific work (if any) on which it is based. We need to keep in mind, as well, the past
uses and misuses of biological knowledge mentioned in this book
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CONCLUSION
We’ve examined the meaning of bioethics and examined only a few of the many bioethical
issues in this course. Like all the others, the last issue, genetic technology, certainly raises
many questions we should all learn more about so we can make wise decisions about them.
Bioethics forces us to ask what kind of society and what kind of world we want. Should we
build a society in which only those who can afford it get adequate medical care and level of
well-being? How can we prevent inhuman medical and scientific experiments in the future
while maintaining commitment to scientific progress? How can we deal with the threats to
our security without destroying the fundamental rights and freedoms that we have struggled
to achieve? Should we go “full steam ahead” with all medical technology or do we need to
examine them more carefully and control or even stop some of them? Should we alter the
genetic code of human beings? If so, who decides and for what purposes? Should we start
considering the welfare of other species, too, like the animals we test our products on or
even the animals we routinely eat? Should we spend so much time on expensive
technologies that benefit a relatively small and affluent population while simple steps like
cleaner water could save the lives of many more? Should we continue to live in a world
where entire areas and whole generations are wiped out by curable, treatable and
preventable diseases? These and other questions are what bioethics examines. It tries to do
what Potter mentions above – provide greater knowledge about biological and medical
science but as part of a wider mission to develop moral or ethical wisdom to guide us in
deciding how we should live.
On a global level, it is apparent that the social and health benefits enjoyed by
Canadians and other rich countries have not spread around the world. Few countries can
afford the public health care systems or, in some cases, even the basic public health
measures like clean water and sanitation implemented in the West. Despite impressive
efforts by the UN, the World Health Organization and others to implement vaccination
programs, in Africa, millions of people still die or suffer from preventable, treatable or
curable illnesses and infectious diseases. Only recently have western pharmaceutical
companies, governments and trade organizations agreed to provide cheap versions of drugs
to treat people with HIV/AIDS in poor countries. Meanwhile, the AIDS pandemic has been
decimating Africa for the last 10 to 15 years, resulting in about 17 million deaths. The
resistance to providing these drugs is based on the protection of patents and fear of lost
profits for the pharmaceutical companies, most of which are based in the developed world
(McGeary). Fortunately, the availability of drugs has improved recently but serious
problems remain. In many ways, if we examine infant mortality, life span and illness and
death due to infectious diseases, the situation in poor countries resembles the situation of
the average person in the so-called advanced countries from one hundred years ago. For
sub-Saharan Africa, life-expectancy is still an average of 49.6 years while 32% of the
population is undernourished (United Nations Development Program). On a global level,
adequate health care is for those who can afford it.
It is important to remember that many of the changes that led to extended life span
and better health for people were not just the result of increased scientific knowledge or
improved technology. At least as crucial were political developments and decisions that
led to improved social and economic conditions for a larger segment of the population.
Medical breakthroughs like vaccination wouldn’t have made a great impact if governments
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Winter, 2015
hadn’t also followed this with massive public inoculation campaigns that reached even the
poorest members of society. Without political pressure vaccination, improved diets, cleaner
water, better hygiene and sanitation and better working and living conditions and higher
wages would not have happened. Neither would have public health insurance taken hold in
Canada and elsewhere. Even if a country has the most advanced medical technology in the
world, it will do little good if only a few can gain access to it. Thanks to the organization
and political struggles of past generations, access to both basic goods as well as more
advanced medical care was opened to a larger segment of society.
This brings us again to what Potter above calls a “new wisdom” that bioethics is
aiming for. This new wisdom would help us in our moral and ethical thinking and provide
ethical principles to assess new technologies and treatments. As mentioned, the lives and
health of people are determined not just by technology and science but by the choices we
make as a society. Hopefully, we will be encouraged to ask even more fundamental
questions about who should have access to these technologies and to what kind of society
we want, what kind of ideas we believe in and even what it means to be a human being and
a free being. These are some of the questions that bioethics and ethics raise in the hopes that
this generation or the next will find just and equitable – ethical – answers to them.
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